in  t|)c  Citp  of  i^eto  gork 
College  of  ^fipsiicians;  anb  ^urgeon^ 


Reference  %ibvavv 


Dental  Fund 


r 


ORAL    ANESTHESIA 


Oral  Abscesses  —  A  Pathological  Study  cf 

Infectious  Foci  in  the  Mouth  and  Their 

Relation  to  Somatic  Diseases. 
Oral  Roentgenology  —  A  Roentgen   Study 

of   the  Anatomy    and    Pathology  of  the 

Oral  Cavity. 


ORAL  ANESTHESIA 

LOCAL  ANESTHESIA  IN  THE 
ORAL  CAVITY 


TECHNIQUE   AND    PRACTICAL   APPLICATION   IN  THE 
DIFFERENT   BRANCHES   OF   DENTISTRY 


BY 

KURT   H.    THOMA,   D.M.D. 

ASSISTANT   PROFESSOR   OF   ORAL   PATHOLOGY  AND  MEMBER   OF  RESEARCH  DEPARTMENT 
HARVARD     UNIVERSITY    DENTAL     SCHOOL.         INSTRUCTOR    ESf     DENTAL     ANATOMY, 
HARVARD    UNIVERSITY    MEDICAL    SCHOOL.         ORAL   SURGEON    ROBERT    BRECK 
BRIGHAM  HOSPITAL.      VISITING   ORAL   SUllGEON,   LONG  ISLAND   HOSPITAL. 
MEMBER   NATIONAL,   STATE,   AND   LOCAL  DENTAL   SOCIETIES  AND   IN- 
TERSTATE  ASSOCIATION    OF    ANESTHETISTS.        FELLOW    IN    THE 
AMERICAN     ACADEMY     OF     DENTAL      SCIENCE.        ASSOCIATE 
FELLOW     OF   THE     AMERICAN    MEDICAL    ASSOCIATION. 


Second  Edition,  Revised  with  yg  Illustrations 


BOSTON 

M.  C.  CHERRY 

22    Seymour    Street 
1920 


z.  3  -    2-^  ^36. 


{The  right  of  reproduction  of  the  original  illustrations  is  strictly  reserved) 

Copyrighted  at  the  Registry  of  Copyrights,  Washington,  D.  C,  igi4 
Revised,  reprinted  and  recopyrighted,  Washington,  D.  C,  ig20 


All  rights  reserved 


T?KS  10 


TO 

HERMANN  F.  THOMA 

:SiY    FATHER 

THIS  VOLU.ME  IS  FONDLY  DEDICATED 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/oralanesthesialoOOthom 


PREFACE   TO   THE    SECOND   EDITION 

WITH  the  introduction  of  local  anesthesia  into  this 
country,  a  great  demand  was  created  for  instruction 
among  members  of  the  dental  profession.  The  writer  had 
the  pleasure  of  introducing  this  method  into  the  oper- 
ative clinic  of  the  Harvard  Dental  School,  and  though 
it  was  at  first  viewed  with  suspicion  it  soon  became 
recognized  as  one  of  the  greatest  boons  in  the  relief  of 
suffering  in  the  dental  chair.  Invitations  for  papers  and 
clinics  at  various  dental  conventions  which  were  largely 
attended  and  demands  for  postgraduate  instruction  be- 
came more  and  more  numerous;  and  to-day  local  anes- 
thesia is  part  of  the  dental  curriculum  in  every  school  and 
in  use  in  ever>^  modern  dental  office.  It  has  certain  un- 
questionable advantages  over  nitrous  oxide  and  oxygen 
anesthesia  for  oral  operations. 

Correspondence  with  brother  practitioners  grew  daily, 
and  the  great  amount  of  information  sought  by  them, 
together  with  the  desire  to  be  of  assistance  to  his  colleagues, 
stimulated  the  writer  to  present  to  the  profession  a  con- 
cise but  comprehensive  publication,  a  primer,  so  to  speak, 
for  the  busy  practitioner,  going,  however,  sufficiently  into 
fundamentals  to  make  it  a  textbook  for  the  dental  student. 

The  first  edition  of  5000  volumes  having  been  exhausted 
in  a  comparatively  short  time,  and  the  continuous  demand 
for  this  book,  made  it  necessary  to  issue  a  new  edition.  The 
author  has  been  making  use  of  this  welcome  opportunity 
to  entirely  rewrite  the  work.     The  volume  is  opened  with  a 

7 


8  ORAL  ANESTHESIA 

description  of  the  nature  of  pain  and  fear,  the  two  emotions 
which  are  so  closely  related.  It  is  not  sufficient  to  control 
pain  alone.  The  successful  anesthetist  and  surgeon  should 
also  promote  a  helpful  and  cooperative  attitude  in  the 
patient.  Some  of  the  new  substitutes  for  cocain  have 
received  consideration  in  the  chapter  dealing  with  drugs  and 
the  name  "Procaine"  has  been  substituted  for  "novocain" 
in  the  entire  volume,  as  the  latter  is  now  manufactured  in 
the  United  States  and  licensed  by  the  Federal  Trade 
Commission  under  this  new  trade  name.  The  Procaine- 
Metz  manufactured  in  New  York  by  the  H.  A.  Metz  Lab- 
oratories has  been  found  as  efficient,  in  every  respect,  as 
the  imported  novocain  and  is  referred  to  in  the  work  en- 
tirely when  the  name  "Procaine"  is  used.  The  T  tablets, 
the  manufacturing  of  which  was  promised  in  the  first  edi- 
tion, came  into  the  market  after  a  short  delay  and  have  been 
giving  great  satisfaction.  An  H  tablet  is  now  being  made 
containing  three  times  as  much  as  a  single  T  tablet  which 
facilitates  the  preparation  for  the  solution  for  those  who 
use  local  anesthesia  extensively.  The  technique  of  the 
injections  described  in  the  first  volume  has  stood  the  test 
of  time,  but  new  methods  have  since  then  been  developed  and 
have  been  incorporated  in  this  edition.  The  extraoral  methods 
which  are  of  great  value  in  war  surgery  and  extensive  oral 
operations  in  general,  have  been  described  carefully  and  many 
new  illustrations  have  been  added  to  make  the  text  more 
comprehensive  or  to  replace  some  crude  figures  of  the  earlier 
edition.  The  chapter  on  111  Effects,  Failures,  Accidents,  and 
Postoperative  Sequelae  has  been  entirely  changed,  more 
careful  consideration,  experience,  and  research  work  having 
done  a  great  deal  towards  better  understanding  of  these 
conditions.  In  the  last  chapter,  on  Practical  Application, 
the  subject  has  been  greatly  condensed,  leaving  out  material 
not  strictly  pertaining  to  local  anesthesia. 

A  list  of  literature  on  local  anesthesia  and  subjects  co- 


PREFACE   TO   THE  SECOND  EDITION  9 

related  has  been  added  to  give  due  credit  to  other  writers  and 
operators  who  have  aided  in  the  development  of  local  anes- 
thesia, as  research  workers  or  teachers.  While  there  are 
still  some  disputed  points  of  minor  importance  and  slight 
deviation  of  individual  technique,  no  one  has  introduced 
any  radical  changes  since  the  first  publication  of  this  book. 
The  writer  has  received  valuable  assistance  from  Dr. 
Leonard  D.  Nathan  in  the  preparation  of  the  manuscript 
and  proofreading  for  this  edition,  and  five  excellent  ana- 
tomical drawings  by  Miss  Herford  should  also  receive  grate- 
ful acknowledgment. 

Kurt  H.  Thoma 

43  Bay  State  Ro.\d 

Boston,  Massachusetts 
July  5.  1919 


CONTENTS 

PAGE 

I.  THE    NATURE    OF    PAIX    AND    FEAR    AND    METHODS    OF 

CONTROLLING  THEM 15 

II.  SPECIAL  ANATOMY  OF   THE   OIL\L   CAVITY 19 

1.  The  Upper  Jaw 19 

The  Anterior  Surface 20 

The  Infratemporal  Surface 23 

The  Alveolar  Process 23 

The  Palatal  Process 26 

The  Maxillary  Sinus 29 

The  Nasal  Cavity 29 

2.  The  Lower  Jaw 29 

The  External  Surface 29 

The  Internal  Surface 34 

Mandibular  Foramen 34 

3.  Sensory  Innervation  of  the  Oral  Tissues  and  the  Face  .    .  37 

The  Trigeminal  Nerve 38 

Ophthalmic  Di\dsion 39 

Maxillary  Division 42 

Sphenopalatine  Ganglion 44 

Mandibular  Division      48 

Otic  Ganglion 51 

Submaxillary  Ganglion      52 

Table  of  Sensory  Nerve  Supply  of  Face  and  Oral  Tissues  ....  52 

III.  INSTRUMENTARIUM 54 

Syringe  No.  i  for  Intraoral  Injection 54 

Needles ^s 

Boiling  Cups 57 

Glass  Jar e  9 

Bottle  for  Ringer  Solution      59 

Glass  Tray  with  Cov^er eg 

Alcohol  Lamp 60 

Syringe  No.  2  for  Extraoral  Injections 60 

Needles 5i 

IV.  PILVRMACOLOGV  OF  DRUGS  USIOD  FOR  LOCAL  ANESTHESIA  .  62 

Cocain 62 

Requirements  of  a  Substitute  for  Cocain 63 

Apothesine 64 

Novocain 64 

Procaine 6^ 

Table  of  Comparative  Toxicity  of  Cocain  and  Novocain      67 

Adrenalin 70 

Suprarenin  Syntheticum 71 

Solvent  .Medium ye 

Distilled  Water '  77 

1 1 


12  CONTENTS 

PAGE 

Procain-Suprarenin  Combined •. 80 

Ampules 80 

Prepared  Solutions 81 

Seidel's  Method 81 

Tablets.     Author's  Method 81 

List  of  Tablets  of  Metz  Laboratories 82 

Procaine  Pluglets 83 

Method  of  Preparing  the  Solution 83 

Requirements  of  a  Solution  Prepared  from  Tablets      84 

V.  PREPARATION  OF  THE  PATIENT 85 

Preanesthetic  Medication 86 

Local  Preparation 87 

Preparing  the  Mucous  Membrane 87 

Preparing  the  Skin 87 

VI.   SPECIAL  TECHNIQUE  OF  LOCAL  ANESTHESIA 89 

Absorption  Anesthesia 


Application  to  the  Oral  Mucous  Membrane 90 

Nasal  Application 91 

Application  to  Exposed  Pulp 91 

Infiltration  Anesthesia 93  . 

Infiltration  of  the  Skin  and  Mucous  Membrane 96 

Infiltration  Method  for  Anesthetizing  Individual  Teeth 98 

Injection  on  Labial  or  Buccal  Side  of  Upper  Jaw 102 

Injection  on  the  Lingual  Side  of  Upper  Jaw .  103 

Injection  on  the  Labial  Side  of  the  Mandible 103 

Injection  on  the  Lingual  Side  of  the  Mandible  .    .    .    .   ■ 104 

For  upper  Central  Incisors 104 

Lateral        "  105 

Cuspids 105 

First  Bicuspids 106 

Second  Bicuspids 106 

First  Molars 106 

Second  Molars 106 

Third  Molars  ^ 107 

Lower  Incisors 109 

Infiltration  Method  for  Anesthetizing  a  Number  of  Adjoining  Teeth  .  109 

Conduction  Anesthesia no 

Intraoral  Methods      113 

Pterygomandibular  Injection 113 

Mental  Injection 123 

Buccinator  Injection 126 

Sphenomaxillary  Injection      126 

Zygomatic  Injection 132 

Infraorbital  Injection 134 

Incisive  Injection 138 

Palatine  Injection 139 

Table  for  Infiltration  Anesthesia  for  the  Teeth  only 140 

Table  for  Infiltration  Anesthesia  for  Teeth  and  Soft  Tissues    .    .    .  141 

Table  for  Conduction  Anesthesia  for  the  Teeth  only 142 

Table  for  Conduction  Anesthesia  for  Teeth  and  Soft  Tissues  ....  143 

Extraoral  Methods 144 

Mandibular  Injection 144 

Pterygomandibular  Injection 148 

Maxillary  Injection      152 

Infraorbital  Injection 157 


CONTENTS  13 

PAGE 

VII.   ILL  EFFECTS,  FAILURES,  ACCIDENTS,  AND   POSTOPERATIVE 

SEQUELAE 159 

111  Effects i^g 

Pain .'.".".'!  159 

Toxic  Effects len 

Failures      leg 

Anatomical  Conditions leg 

Faulty  Instruments  and  Technique 160 

Deteriorated  Drugs      160 

Accidents i5j 

Breaking  of  Needle 161 

Entering  Blood  Vessel 161 

Local  Vasoconstriction 161 

Centering  Nerve  Trunks 161 

Anesthesia  of  Motor  Fibers 162 

Psychic  Shock 162 

Syncope [    ]  164 

Postanesthetic  and  Postoperative  Effects 165 

Tissue  Lesions ige 

Edema ^55 


After  Pain 


167 


Prolonged  Anesthesia 170 

VIII.    PRACTICAL  APPLICATION  OF  LOCAL  ANESTHESIA  IN  DEN- 
TISTRY AND  ORAL  SURGERY      171 

Cavity  Preparation      j^i 

Crown  and  Bridge  Work 172 

Pulp  Extirpation 17, 

Treatment  of  Pyorrhea  Alveolaris 174 

Diagnosis  of  Trifacial  Neuralgia [    ,  174 

Alcohol  Injections  for  Major  Neuralgia 1 74 

Oral  Surgery j;74 

Extraction  of  Teeth 174 

Operations  on  the  Jaws 1 74 

Operations  on  the  Maxillary  Sinus 174 

Resections  of  Jaws 17  e 


PART  I 

THE    NATURE   OF  PAIN  AND  FEAR  AND   METHODS 
OF   CONTROLLING   THEM 

THE  sensation  of  pain  is  brought  about  by  the  stimu- 
lation of  receptors,  which  are  highly  specialized 
organs,  capable  of  receiving  and  transmitting  stimuli  through 
sensory  neurons  to  the  cerebral  cortex.  These  receptors 
are  widely  distributed  over  the  body,  being  present  in  the 
skin  and  in  the  lining  membranes,  such  as  the  periosteum 
and  perichondrium.  All  the  oral  tissues  and  particularly 
the  teeth  are  especially  well  supplied.  Pain  is  a  protective 
device  which  gives  information  regarding  conditions  which 
affect  the  normal  state  of  the  body.  It  registers  injury 
and  disease,  and  while  being  an  ally  under  these  circum- 
stances, it  becomes  a  hindrance  when  operative  meas- 
ures are  necessary  to  eliminate  abnormal  conditions.  The 
intensity  of  pain  varies.  Some  parts  of  the  body  are  much 
more  susceptible  than  others,  as  evidenced  by  the  need  of  a 
stronger  stimulus  to  produce  a  reaction  from  the  palm  of 
the  hand  than  from  the  back.  Race,  age,  sex,  general 
health,  and  the  susceptibility  of  certain  individuals  are 
factors  which  explain  differences  in  the  intensity  of  pain. 
Education,  with  its  promotion  of  self-control,  is  an  important 
influence  in  controlling  the  closely  associated  emotion  of 
pain  —  fear,  which,  in  turn,  may  cause  an  enormous  ex- 
aggeration of  the  actual  condition.  It  must  always  be 
remembered  that  the  person  concerned,  consciously  or 
unconsciously,  recalls  instances  similar  to  the  present,  in 
which  he  was  actually  the  sufferer,  or  of  which  he  has  knowl- 


1 6  OR^-iL  ANESTHESIA 

edge  only  from  hearsay;  and  furtlierinore,  there  is  a  prob- 
abUit}-  that  ph^'logenetic  experience,  that  of  progenitors 
acquired  during  the  past  centuries,  may  automatically  give 
a  reaction. 

Pain,  an  internal  body  sensation,  as  well  as  fear,  an  outside 
influence,  of  Avhich  dread  is  a  diminutive  and  fright  an  inten- 
sified condition,  causes  certain  changes  in  the  body.  Crile, 
in  his  excellent  work  on  "  Anoci-association "  explains  these 
emotions  by  a  theor\'  resulting  from  phylogenetic  habits,  and 
so  he  finds  that  our  ancestors  had  two  principal  methods  of 
defending  themselves,  namely  fight  and  flight.  The  means  in 
both  cases  was  muscular  acti\dty,  which,  if  carried  to  an 
extreme,  resulted  in  physical  exhaustion.  To-da}^,  when 
placed  in  a  similar  position,  fight  and  flight  are  not  counte- 
nanced. The  discharge  of  energ}'  therefore  results  in  no  actual 
work,  and  if  the  stimulation  is  strong  enough  and  the  expendi- 
ture of  energy  rapid,  the  condition  is  designated  ''  shock." 

Shock  may  be  produced  by  physical  causes,  such  as 
pain,  injury,  hifection,  and  muscular  exertion,  or  by  psychic 
conditions,  such  as  fear,  dread,  and  worry.  Crile  presented 
evidence  from  histological  and  clinical  observation  proving 
that  all  these  conditions  cause  ph^'sical  alterations  in  the 
ceUs  of  the  brain,  the  suprarenal  glands,  and  the  liver.  In 
dental  and  oral  surgical  operations,  most  of  these  factors  are 
present  in  a  larger  or  smaller  measure  and  should  be  elimi- 
nated as  far  as  possible. 

The  ph3-sical  stimuli  are  transmitted  to  the  brain  whether 
the  patient  is  conscious  or  unconscious.  Crile  states  that  a 
general  anesthetic  alone  does  not  prevent  stimulation  of 
the  cells  of  the  brain,  nor  physical  shock;  but  this  can  be 
well  accompHshed  by  a  local  anesthetic  which  blocks  the 
transmission  of  impulses  along  the  nerve.  Psychic  stimu- 
lation, however,  is  not  taken  care  of  by  this  method  and 
presents  a  problem  of  a  much  more  complex  character.  The 
thought  of  the  pending  operation  and  of  the  general  anes- 


THE  NATURE  OF   FAIN  17 

thetic  may  often  cause  the  prospective  patient  days  and 
nights  of  anxiety  and  dread.  The  sight  of  the  operating 
room,  thoughtless  conversation  by  the  nurses,  the  unin- 
tentional expression  of  danger  by  the  operator,  confusion 
in  preparing  for  the  operation,  and  finally  the  sight  of  the 
operation  and  the  flow  of  blood,  are  factors  which  may 
arouse  fear  and  fright.  How  can  these  emotions  be  con- 
trolled? A  general  anesthetic  will  eliminate  the  psychic 
effects  connected  with  the  operative  procedures;  Crile  there- 
fore advocates  a  combination  of  local  and  general  anesthesia 
to  attain  a  state  as  free  as  possible  from  harmful  stimuli, 
"  noci-associations,"  so  as  to  reach  a  state  of  "  anoci-asso- 
ciation." 

In  dental  and  minor  oral  surgical  operations,  the  opera- 
tive procedure  is  not  so  severe  but  that  the  average  patient 
can  bear  to  have  it  performed  while  fully  conscious,  while 
the  psychic  effects  can  be  controlled  in  a  large  percentage 
of  cases  by  careful  management  of  the  patient,  harmonious 
environment,  tactful  reception  by  the  office  staff,  consid- 
erate treatment  by  the  nurse,  as  well  as  noiseless  and  un- 
ostentatious preparations  for  the  operation.  The  person- 
ajity_Qf  the  operalar  is  perhaps,  thp,_most  important  factor. 
He  should  secur^Jroni^tlieJirst  thejconfidence  of  the  patient 
by  a  sympathetic^  and  convincin^;_attitude,  by  which  the 
patleiTt  cannot  fail  to  be  reassured.  The  operator  should 
be  in  full  control  of  any  situation  that  may  arise,  and  should 
act  unpretentiously  without  arousing  the  patient's  Jears 
and  doubts.  Since  the^atient's  nerves  are  keyed  to  the 
highest  pitch,  sometimes  the  mere  mention  of  the  words 
"  knife,"  "hemorrhage,"  or  "  infection,"  may  cause  disastrous 
results.  The  patient  should  never  be  permitted  to  become 
conscious  ^T^anymicertainty  or  indecision.  The  operator 
should  work'  quietly,  following  step  by  step  the  technique 
decided  upon  and  from  time  to  time  reassure  the  patient.  If 
the  operation  is  long  and  tedious,  as  in  the  case  of  uneruptcd 


o 


1 8  ORAL  ANESTHESIA 

l:hird  molars,  the  patient,  as  well  as  the  operator  and  his 
assistant,  should  rest  occasionally;  and  the  patient  should 
be  made  to  realize  that  the  anesthetic  will  last  longer  than  is 
necessar}^  for  the  painless  completion  of  the  operation. 

With  the  modern  methods  of  conduction  anesthesia, 
pain  can  be  entirely  controlled.  A  local  anesthetic  is  prefer- 
able when  the  operation  is  to  be  performed  in  the  office, 
where  it  is  difficult  to  prepare  the  patient  properly.  It  does 
away  with  a  general  anesthetist  and  eliminates  the  dangers 
attending  general  anesthesia.  The  absence  of  vomiting  after 
the  operation,  the  cooperation  of  the  patient  under  the 
local  anesthetic,  and  the  fact  that  the  field  is  almost  blood- 
less are  factors  which  facilitate  the  work  of  the  operator. 

Notwithstanding  these  great  advantages,  the  cases  for 
local  anesthesia  must  be  selected  carefully.  Children  are 
usually  poor  subjects,  although  very  intelligent  older  chil- 
dren are  sometimes  exceptions.  For  some  patients,  a 
general  anesthetic  is  contra-indicated  and  in  such  cases, 
danger  can  be  avoided  by  the  use  of  local  anesthesia.  Many 
adults  will  consent  to  nothing  but  a  general  anesthetic. 
The  excitable,  nervous,  and  timid  patients  who  dread 
consciousness  of  the  operation  can  sometimes  be  satisfac- 
torily prepared  by  preanesthetic  medication,  such  as  the 
administration  of  bromural,  veronal,  or  morphia. 


PART   II 

SPECIAL   ANATOMY   OF   THE    ORAL    CAVITY 

THE  use  and  development  of  local  anesthesia  necessi- 
tates a  thorough  study  of  the  bony  structures  of 
the  maxillae  as  well  as  the  nerves  and  vessels  supplying 
the  various  tissues  and  organs  of  the  mouth.  Numerous 
openings  which  can  be  found  on  the  surface  of  the  jaws  — 
transmitting  arteries,  veins,  nerves  and  lymph  vessels  — 
furnish  a  possibility  of  infiltrating  the  inner  part  of  the 
bones  with  an  anesthetic  solution,  injected  under  the  mucous 
membrane.  Smaller  nerve  branches  and  larger  nerve  trunks 
can  be  conveniently  reached  in  various  places;  but  an  ac- 
curate knowledge  of  the  important  landmarks  is  imperative 
in  determining  their  exact  location. 

1.   The  Upper  Jaw 

The  upper  and  lower  jaws  are  dissimilar  in  their 
make-up.  They  vary  in  structure  as  well  as  in  shape  and 
appearance.  Both  are  covered  with  periosteum  through 
which  small  nutrient  vessels  enter  the  bone  by  way  of 
the  Haversian  canals. 

The  body  of  the  maxillary  bone  incloses  a  large  cavity, 
the  maxillary  sinus  (O.  T.  Antrum  of  Highmore),  the  walls 
of  which  are  very  thin.  Of  the  spaces  and  processes  which 
it  presents  for  examination,  those  of  special  interest  to  us 
are  the  anterior  and  infratemporal  surfaces,  the  zygomatic 
and  palatal  processes,  and  particularly  the  alveolar  process, 
which  contains  the  teeth. 

The  anterior  surface  (O.  T.  external  or  facial  surface) 
presents  an  elevation  over  the  root  of  the  cuspid  tooth, 
called    the   canine   eminence,   which   separates   the   incisive 

19 


20 


ORAL  ANESTHESIA 


FiGURK    I 

Side  view  of  upper  and  lower  jaw,  showing  attachment  of 
muscles.  A.  Temporalis  m.  B.  Masseter  m.  C.  Lavator  an- 
gvili  oris  m.  D.  Compressor  nasi  m.  E.  Depressor  septi  m. 
F.  and  H.  Buccinator  m.  G.  Masseter  m.  K.  Depressor 
anguli  oris  m.  L.  Depressor  labii  inferior  m.  M.  Depressor 
menti  m.    N.   Platysma  myoides  m. 

from  the  canine  fossa.  Above,  the  incisive  fossa  gives  origin 
to  the  compressor  nasi;  below  and  more  to  the  median  line, 
to  the  depressor  septi  muscle  (O.  T.  depressor  alae  nasi). 
The  canine  fossa  gives  attachment  to  the  levator  anguli 
oris    muscle.      The   infraorbital   foramen   opens   above   the 


SPECIAL   ANATOMY  OF   THE  ORAL   CAVITY  21 

origin  of  this  muscle.  It  is  situated  immediately  below  the 
centre  of  the  infraorbital  ridge  and  above  the  root  apex  of 
the  first  bicuspid  tooth.     Its  distance  from  the  infraorbital 


Figure  2 
P"ront  view  of  upper  and  lower  jaw,  showing  small  foramina 
in  the  alveolar  process  made  use  of  in  infiltration  anesthesia. 

margin  is  normally  7  mm.  in  the  adult.  The  infraorbital 
foramen  is  the  outlet  of  the  infraorbital  canal,  and  its  course 
shows  a   decided    downward   direction.     The    canine    fossa 


22 


ORAL  ANESTHESIA 


which  continues  from  this  point  towards  the  alveolar  process 
varies  greatly  as  to  size  and  shape.  Its  formation  depends 
on  the  prominence  of  the  infraorbital  margin,  the  develop- 


FlGUEE   3 

Side  view  of  upper  and  lower  jaw,  showing  small  foramina  in 
the  alveolar  process  of  the  maxillary  bone  and  dense  cortical 
surface  of  mandible. 

ment  of  the  zygomatic  and  the  position  and  direction  of 
the  alveolar  processes. 

The  Infratemporal  Surface  (O.  T.  posterior  or  zygo- 
matic surface)  is  convex,  directed  backward  and  inward. 
It  forms  part  of  the  zygomatic  fossa.     From  the  anterior 


SPECIAL   ANATOMY   OF   THE  ORAL   CAVITY  23 

surface  it  is  separated  by  the  zygomatic  process.  At  its 
posterior  and  inferior  part  is  a  rounded  eminence,  the  tuber 
maxillare.  Besides  giving  attachment  to  a  few  fibers  of  the 
external  pterygoid  muscle,  it  presents  a  greater  or  lesser 
number  of  openings  which  are  usually  more  marked  in  youth 
than  in  old  age.  These  are  in  the  neighborhood  of  the  root 
of  the  third  molar  and  probably  transmit  vessels  which  fur- 
nish nutrition  to  the  inner  part  of  the  bone  and  give  oppor- 
tunity for  local  anesthesia. 

The  posterior  alveolar  foramina  are  located  higher  up. 
There  are  one  or  two,  seldom  three  foramina  of  larger  size. 
These  are  openings  to  very  fine  canals  which  run  along 
the  outer  wall  of  the  maxillary  sinus  and  transmit  the 
posterior  alveolar  vessels  and  nerves  which  innervate  the 
molar  teeth. 

The  alveolar  process  which  furnishes  the  bony  support 
to  the  roots  of  the  teeth  is  continuous  from  the  tuberosity 
on  one  side  to  the  tuberosity  on  the  other.  It  is  made  up 
of  an  outer  and  inner  plate  of  hard,  solid  bone  called  cortex 
between  which  plates  extend  many  small  trabeculae  of 
bone.  These  form  a  reticular  structure  which  incloses  the 
medullary  spaces,  the  continuity  of  which  is  interrupted  only 
by  the  alveolar  sockets.  A  stratum  durum,  dense  bone, 
forms  the  wall  of  the  dental  alveoli,  the  outer  and  inner 
aspects  of  which  are  at  the  cervical  part,  fused  into  the 
cortical  plate,  especially  on  the  labial  and  buccal  sides. 
On  the  outside  of  the  bone  vertical  ridges  corresponding 
with  the  roots  of  the  teeth  are  distinctly  visible  and  indicate 
the  thinness  of  the  bone.  This  is  especially  the  case  over 
the  roots  of  the  central  incisors,  the  cuspids,  and  bicuspids, 
and  these  teeth  therefore  can  be  easily  and  quickly  anes- 
thetized by  infiltration.  There  are  numerous  small  canals, 
the  openings  of  which  are  clearly  visible,  which  commu- 
nicate with  the  marrow  .spaces  and  allow  the  anesthetic 
solution  to  pass  inside  the  bone.     There  it  affects  the  dental 


24 


ORAL  ANESTHESIA 


plexus  and  small  dental  rami  before  they  enter  the  alveolar 
socket  to  supply  the  peridental  membrane  and  the  pulps 
of  the  teeth.  Posteriorly  in  the  region  of  the  molars  the 
outer  plate  of  the  alveolar  process  becomes  thicker  and 
much  more  dense  in  character  on  account  of  the  zygomatic 
process  (O.  T.  malar  process)  which  takes  its  origin  directly 
over  the  first  or  second  molar  tooth.  When  the  zygomatic 
process  extends  far  towards  the  cervical  margin  of  the  teeth, 


Figure  4 
Side  view  of  maxillary  bone  with  outer  cortical  plate 
removed,  showing  inner  structure  of  bone  and  relation  of 
the  teeth  to  the  maxillary  sinus. 

anesthetization  of  the  teeth  becomes  impossible.  There 
are,  however,  occasional  cases  when  the  alveolar  process 
is  well  formed  and  long  enough  even  in  the  molar  region 
to  bring  the  apex  of  the  buccal  roots  of  the  molars  within 
reach  of  the  anesthetic  solution.  The  posterior  extremity 
of  the  alveolar  process  takes  part  in  the  formation  of  the 
tuber  maxillare.  In  this  region  the  bone  is  thin,  and  pre-, 
sents  many  small  foramina,  as  previously  described.  The  inner 
plate  of  the  alveolar  process  is  heavier  and  stronger;  small 
pores  are  evenly  distributed  over  its  entire  surface.  How- 
ever, the  roots,  especially  the  apices,  are  generally  a  con- 


SPECIAL   ANATOMY  OF   THE  ORAL   CAVITY  25 

siderable  distance  from  the  surface,  especially  in  the  case  of 
single-rooted  teeth,  and  infiltration  from  this  side  cannot 
be  depended  upon.  On  the  other  hand,  if  there  are  palatal 
roots  present  as  in  first  bicuspids,  and  first  and  second 
molars,    complete   anesthesia   of   the    tooth   by   infiltration 


Figure  5 
Skull,  showing  location  of  incisive  and  palatal  foramina 
in  the  adult. 

can  only  be  secured  when  the  solution  is  injected  both  at 
the  buccal  and  palatal  sides. 

The  Palatal  Process  joins  the  maxillary  bone  at  the 
upper  extremity  of  the  alveolar  process.  It  projects  hori- 
zontally towards  the  median  line,  where  it  meets  its  fellow  of 
the  opposite  side  and  so  forms  the  roof  of  the  mouth.     It 


26  ORAL  ANESTHESIA 

usually  forms  a  distinct  angle  where  it  joins  the  alveolar 
process,  and  the  well-rounded  appearance  of  the  vault  is 
due  to  the  filling  in  of  this  region  by  an  abundance  of  con- 
nective tissue  containing  the  palatal  glands. 

The  incisive  foramen  lies  in  the  median '  line  immediately 
behind  the  incisor  teeth.  The  distance  from  the  alveolar 
margin    is  usually  8  mm.   in  the  adult.      It  is  formed  by 


Figure  6 
Skull,  showing  incisive  and  palatal  foramina 
in  a  child  between  five  and  six  years  of  age. 

four  canals,  two  laterally  for  the  descending  palatine  arteries, 
one  anteriorly  and  one  posteriorly  directly  in  the  median 
line  for  the  nasapalatine  nerves.  The  direction  of  the  in- 
cisive canal  is  not  vertical,  but  is  inclined  slightly  forward 
and  downward,  and  therefore  a  needle  inserted  enters 
easily  along  its  course.  The  incisive  foramen  is  covered  by 
a  protuberance  of  the  soft  tissue  known  as  the  papilla  pal- 
atina,  the  centre  of  which  lies  exactly  in  the  axis  of  the 
canal.  It  transmits  the  nasopalatine  nerves  and  descending 
palatine  arteries,  which  supply  the  anterior  part  of  the  palate. 


SPECIAL   ANATOMY  OF   THE  ORAL  CAVITY  27 


Figure  7 
Roentgen  picture,  showing  outline  of  the  superior  alveolar  canals 
in  the  bony  walls  of  the  maxillary  bone. 

The  palatine  foramina  are  four  in  number,  a  larger  and 
a  smaller  on  each  side  of  the  jaw.  They  are  the  outlets 
of  the  palatine  canals,  which  are  formed  partly  by  the  maxi- 
illar>'  and  partly  by  the  palatal  bone.  The  larger  foramen  is 
anterior  and  transmits  the  anterior  palatine  nerve  and 
vessels,  which  are  in  no  way  connected  with  the  teeth  but 


28 


ORAL  ANESTHESIA 


supply  the  soft  tissues  of  the  posterior  part  of  the  hard 
palate.  Its  location  varies  according  to  the  age  of  the 
patient  and  always  lies  medial  to  the  last  erupted  molar. 
In  a  child  under  six  years,  it  is  found  medial  to  the  second 
temporary  molar;  later,  up  to  the  age  of  ten  or  eleven, 
medial  to  the  first  permanent  molar,  and,  up  to  the  erup- 


FlGURE    8 

Section  through  the  two  maxillary  bones,  showing 
nasal  cavity  and  on  each  side  floor  of  maxillary 
sinus.     Note  relation  of  the  teeth, 

tion  of  the  wisdom  tooth,  palatally  to  the  second  molar. 
The  smaller  palatine  foramen  transmits  the  middle  palatine 
nerves  and  vessels  which  supply  the  soft  palate.  Its  loca- 
tion is  slightly  posterior  to  the  larger  foramen,  and  as  it  is 
undesirable  to  produce  anesthesia  of  the  soft  palate,  care 
must  be  exercised  to  confine  the  injection  to  the  region  of 
the  larger  palatine  foramen. 

The   maxillary    sinus    (O.   T.   Antrum    of  Highmore)   is 
only  of  interest  to  anesthetists  on  account  of  its  walls  con- 


SPECIAL  ANATOMY  OF   THE  ORAL   CAVITY  29 

taining  the  posterior  and  anterior  alveolar  canals  through 
which  pass  the  posterior  middle  and  anterior  alveolar  nerves 
and  vessels.  Occasionally  the  molars  and  bicuspids  project 
into  the  sinus  and  form  protuberances  of  considerable  size, 
a  condition  which  may  account  for  some  failures  of  the 
infiltration    method. 

The  nasal  cavity  is  partly  formed  by  the  palatal  pro- 
cesses of  the  maxilla.  The  apices  of  the  incisor  teeth  are  in 
close  relation  to  the  floor  of  the  nose.  Anesthetization  of 
the  nerves  which  supply  the  pulps  of  these  teeth  is  com- 
paratively simple,  by  means  of  applications  to  the  anterior 
part  of  the  floor  of  the  nose,  just  inside  the  nares. 

2.  The  Lower  Jaw 

The  body  of  the  mandible  as  well  as  the  rami  are  sur- 
rounded by  a  layer  of  thick  cortical  bone,  especially  thick 
in  the  molar  region  where  the  bone  is  reinforced  by  the 
massive  internal  and  external  oblique  lines.  The  construc- 
tion of  the  cancellous  part  of  the  mandible  is  similar  to  the 
upper  jaw,  but  the  alveolar  process  is  much  less  distinctive 
than  in  the  maxillary  bone.  The  body  of  the  mandible  and 
the  alveolar  process  will  be  described  together. 

The  external  surface  is  in  general  composed  of  dense 
bone.  Probably,  on  account  of  the  abundant  blood  supply 
from  the  inferior  alveolar  artery,  there  are  none  of  the  small 
foramina  which  are  so  numerous  in  the  maxilla  to  be  found  in 
the  posterior  part  of  the  body  of  the  adult  mandible.  The  thick- 
ness of  the  bone,  the  density  of  the  cortex,  and  the  absence 
of  the  canals  are  conditions  which  account  for  an  unsatisfac- 
tory anesthesia  in  the  posterior  part  of  the  lower  dental  arch 
by  means  of  the  infiltration  method  (see  Figure  3).  Small 
pores,  however,  are  frequently  found  along  the  margin  of 
the  alveolar  process.  These  are  the  outlets  of  tiny  canals 
which  connect  with  the  marrow  spaces  of  the  intraalveolar 


30 


ORAL  ANESTHESIA 


septa  and  transmit  small  nutrient  vessels.  They  are  not 
constant,  often  only  being  found  in  the  incisor  region  but 
sometimes  on  the  alveolar  margin  of  the  bicuspids.  The}^ 
are  rarely  seen  in  the  region  of  the  molar  teeth.  The  use 
of  these  foramina  by  injecting  into  the  gingival  margin  of 
the  gum  around  the  posterior  teeth  of  the  mandible  has 
been  advocated,  but  the  distance  from  the  alveolar  margin 
to  the  apex  of  the  tooth  and  the  uncertain  presence  of  these 


Figure  9 
Side  view  of  mandible  with  outercortical  plate  removed,  showing 
inner  structure  of  bone  and  relation  of  the  teeth  to  the  mandibular 
canal. 

openings  makes  success  too  hazardous  to  advise  the  method 
for  routine  procedure. 

A  different  condition  exists  in  the  mental  region.  The 
mental  fossa  which  lies  directly  under  the  incisor  teeth 
presents  on  each  side  a  number  of  small  foramina  which 
sometimes  extend  as  high  up  as  the  alveolar  margin.  At 
times  one  or  two  larger  openings  can  be  found.  On  the  other 
side  of  the  canine  eminence  below  the  apex  of  the  cuspid 
there  is  also  a  depression  which  corresponds  to  the  canine 
fossa  of  the  upper  jaw.  Here  canals  are  frequently  found 
entering  the  cortex  of  the  bone  (see  Figure  2). 


SPECIAL   ANATOMY  OF   THE  ORAL  CAVITY  31 

The  mental  foramen  is  the  largest  opening  on  the  external 
side.  Its  location  is  important  for  conduction  anesthesia. 
In  the  child  it  is  generally  below  the  first  temporary  molar 
and  in  the  adult  its  location  is  generally  between  the  two 
bicuspids  halfway  between  the  alveolar  margin  and  the 
inferior  border  of  the  mandible.     In  a  great  many  cases, 


Figure  10 
Cross  sections  through  mandible,  showing  thick 
cortical    layer.     The   right    section    is    through 
bicuspid  region,  showing  mental  foramen.     The 
left  section  is  taken  in  front  of  the  jaw. 

however,  the  mental  foramen  may  be  found  further  back 
opposite  the  apex  of  the  second  bicuspid  or  even  distal  to 
it.  The  shape  of  the  foramen  is  normally  oval;  the  hori- 
zontal diameter  is  the  longer  and  measures  usually  three 
to  four  millimeters.  Abnormalities  are  not  uncommon. 
The  author  has  seen  a  foramen  four  times  the  normal  size. 
Occasionally  a  double  opening  is  found.  The  foramen  opens 
distally  and  a  distinct  groove  can  often  be  seen,  a  depression 
made  by  the  mental  vessels  and  nerve. 

The  internal   surface  of  the  body  of  the  mandible  pre- 
sents  only  in    the  anterior  part  conditions  which  may  be 


32 


ORAL  ANESTHESIA 


FiGUEE    II 

Location  of  the  mental  foramen  in  a  child. 


Figure   12 
Location  of  the  mental  foramen  in  an  adult. 


SPECIAL  ANATOMY  OF   THE  ORAL  CAVITY 


33 


■P^^^H 

Itit-^^  '^l^^sitf'^ILJI^HH 

^P^Im 

^^^^^^^HkI^.v             <£^V 

ffr  '  ^^z^ IF                            •  ^^^^H 

^^^ 

'    ^           -.jtujH^ 

Figure  13 
Location  and  shape  of  the  mental  foramen  in  another  adult. 


Figure  14 
Location  of  I  he  menial  foramen  in  the  senile. 

utilized  for  the  purpose  of  producing  anesthesia  of  the  teeth. 
Along  the  lingual  border,  there  are  numerous  openings  which 
are  almost  constant  and  through  which  nutrient  vessels 
enter  the  alveolar  septa.     In  the  cortical  part  around  the 


34  ORAL  ANESTHESIA 

mental  spine  there  are  usually  a  number  of  larger  cana- 
liculi.  These  transmit  end  branches  of  the  sublingual  ar- 
teries which  anastomose  with  the  inferior  alveolar  artery. 

The  mandibular  foramen  (0.  T.  inferior  dental  for- 
amen) is  an  opening  on  the  internal  side  of  the  ramus  through 
which    the   inferior  alveolar  nerve   and  vessels  pass.     The 


Figure  15 
Inner  surface  of  mandible,  showing  outline  of  sulcus 
mandibularis.     (Dotted  line.) 

exact  location  of  this  foramen  is  of  greatest  importance 
to  the  oral  anesthetist,  and  the  effect  that  age  has  upon  its 
position  must  be  carefully  considered.  If  a  line  is  drawn 
over  the  alveolar  border  of  both  a  child's  jaw  and  that  of 
an  adult,  it  will  be  observed  that  the  foramen  is  at  a  very 
much  higher  level  in  the  adult.  If,  however,  the  line  is 
drawn  over  the  cutting  edge  of  the  incisors  and  the  occlusal 
surface  of  the  last  molar,  it  will  be  found  that  there  is  little 
difference  in  the  measurements,  due  to  the  change  in  the 
curvature  formed  by  the  occlusal  surfaces  in  the  teeth. 
The   foramen    is    located   about    two    or    three   millimeters 


SPECIAL  ANATOMY  OF   THE  OIHL   CAVITY  35 


Figure  16 
A  collection  of  mandibles,  showing  variations  of  the 
lingula,  mandibular  foramen,  and  sulcus  mandibularis. 
On  top,  a  child's  mandible;  i^elow,  a  senile  jaw. 


36 


ORAL  ANESTHESIA 


below  such  a  line  and  halfway  between  the  anterior  and 
posterior  border.  If  the  mandible  is  viewed  from  the  front, 
the  foramina  are  not  visible.  They  are  covered  by  the 
projection  of  the  internal  oblique  lines,  the  ramus  being 
not  parallel  with  the  median  line  but  at  an  angle  which 
varies  in  different  individuals  and  races.  The  shape  of  the 
foramen  may  be  compared  with  a  funnel,  and  its  width 
varies  according  to  Stein  between  two  and  eleven  millimeters. 
The  entrance  of  the  alveolar  nerve  and  vessels  is  protected 
anteriorly  by  the  lingula  or  mandibular  tongue,  which  gives 
attachment  to  the  spheno-mandibular  ligament.     The  dis- 


FlGUEE    17 

Anterior  view  of  the  rami  in  three  mandibles,  showing  differences  in 
the  postmolar  triangle,  a.  Internal  oblique  line.  b.  External  oblique 
line.     c.   Post -molar  triangle. 

tance  by  which  the  point  of  the  lingula  extends  over  our 
normal  line  shows  a  marked  difference.  In  the  child  it  is 
only  about  one  to  two  millimeters,  while  in  the  adult  it  is 
five  to  six  millimeters.  The  shape  of  the  lingula  varies 
considerably.    It  may  be  only  an  indistinct  ridge  or  a  promi- 


SPECIAL   ANATOMY  OF   THE  ORAL   CAVITY  '    37 

nent  projection  with  a  rounded  edge  or  a  sharp  outstanding 
margin.  From  the  foramen  a  decided  groove  runs  obHquely 
downward.  This  is  caused  by  the  mylohyoid  nerve  and 
arter}'  which  are  pressed  against  the  bone  by  the  internal 
pterygoid  muscle.  The  muscle  is  attached  to  rough  oblique 
ridges  which  often  form  a  well-marked  protuberance  at 
the  angle  of  the  ramus.  The  internal  pterygoid  muscle 
covers  the  entire  lower  two-thirds  of  the  internal  surface  of 
the  ramus  with  the  exception  of  a  circular  area  forming  a 
shallow  depression  called  sulcus  mandibularis. 

The  anterior  surface  of  the  ramus  forms  the  postmolar 
triangle  and  furnishes  a  landmark  for  the  pterygomandibular 
injection  as  will  be  seen  later.  Its  external  boundary  is 
the  external  oblique  line,  which  starts  from  the  anterior 
margin  of  the  coronoid  process  and  passes  downward  and 
outward  to  the  external  surface  of  the  body  of  the  mandible, 
where  it  is  continued  as  a  well-marked  ridge.  This  is  always 
pronounced  and  can  be  easily  palpated  in  the  mouth.  The 
internal  boundary  is  the  internal  oblique  line.  This  varies 
greatly  in  different  people.  Sometimes  it  is  well  marked, 
while  at  other  times  it  is  indistinct  and  there  is  a  well-rounded 
margin  between  the  anterior  and  internal  surfaces  of  the 
ramus.  The  base  of  the  triangle  is  formed  by  the  distal 
alveolar  margin  of  the  third  molar. 

3.    Sensory  Innervation  of  the  Oral   Tissues  and  the  Face 

The  success  of  local  anesthesia  depends  a  great  deal  on 
the  exact  knowledge  of  the  sensory  innervation  and  nerve 
anastomosis  of  the  parts.  A  thorough  knowledge  of  the 
nerve  supply  and  a  clear  picture  of  the  course  and  distri- 
bution of  the  various  branches  as  well  as  their  surrounding 
anatomical  structures  should  be  constantly  before  the 
operator's  mind. 


38 


ORAL  ANESTHESIA 


FiGUEE    I 8 

Dissected  specimen,  showing   the  trigeminal  nerve. 
13.  Maxillary  division.     26.  Mandibular  division. 

The  Trigeminal  or  Fifth  Cranial  Nerve 

This  supplies  most  of  the  tissues  in  the  mouth.  Its  dis- 
tribution is  extensive  and  it  is  closely  related  to  other  nerves 
through  the  various  ganglia  and  plexuses  of  the  sym- 
pathetic system.      Like  a  spinal  nerve,  it  arises  by  two  roots, 


SPECIAL  ANATOMY  OF   THE  ORAL  CAVITY  39 

an  anterior  which  suppHes  the  motor  branches  and  a  posterior 
which  forms  the  semilunar  gangHon  (0.  T,  Gasserian 
ganghon)  from  which  all  the  sensory  branches  arise.  The 
ganglion  is  situated  in  a  shallow  depression  on  the  anterior 
surface  of  the  pyramidal  portion  of  the  petrous  bone  and  is 
covered  by  the  dura  mater.  The  branches  emerge  from  the 
skull  through  three  different  openings. 

Ophthalmic  Division 

The  ophthalmic  nerve  runs  along  the  cavernous  sinus, 
emerges  through  the  superior  orbital  fissure,  and  at  once 
divides  into  three  branches,  the  lacrimal,  the  frontal,  and 
the  nasociliary  nerves. 

The  lacrimal  nerve  enters  the  orbit  and  runs  along  the 
upper  border  of  the  external  rectus  muscle.  It  communicates 
with  the  zygomatic  nerve  of  the  maxillary  division.  It 
gives  off  filaments  to  the  lacrimal  gland,  the  conjunctiva, 
and  finally  terminates  in  the  skin  of  the  outer  canthus  of 
the  upper  eyelid. 

The  frontal  nerve  is  the  largest  of  the  first  division.  It 
enters  the  orbit  through  the  sphenoidal  fissure  and  divides 
into  two  branches,  the  supratrochlear  and  the  supraorbital. 

The  supratrochlear  branch  passes  above  the  pulley  of 
the  superior  oblique  muscle  and  leaving  the  orbit  by  curving 
around  the  supraorbital  arch,  it  divides  into  two  branches. 
These  pierce  the  orbicularis  and  frontalis  muscles,  supply- 
ing the  skin  of  the  forehead  on  either  side  of  the  middle 
line  and  send  branches  to  the  conjunctiva  and  skin  of  the 
upper  lid.  There  is  also  a  branch  given  off  which  joins  the 
infratrochlear  branch  of  the  nasociliary  nerve. 

The  supraorbital  branch  emerges  through  the  supra- 
orbital foramen.  It  gives  off  filaments  to  the  upper  eyelid 
and  the  mucous  membrane  of  the  frontal  sinus,  terminat- 
ing in  the  cutaneous  and  pericranial  branches.  The  cuta- 
neous  branches    extend    posteriorly   as  far    as    the    vertex, 


40 


ORAL  ANESTHESIA 


Figure  19 
Dissected  specimen  showing  the  trigeminal  nerve. 

while  the  pericranial  ones  are  distributed  in  the  pericranium 
of  the  frontal  and  parietal  bone. 

The    nasociliary    nerve    enters    the    orbit    through    the 
sphenoidal .  fissure  and  passes  to  the  inner  wall  of  the  orbit 


SPECIAL  ANATOMY  OF   THE  OILiL  CAVITY 


41 


until  it  enters  the  cranium  through  the  anterior  ethmoidal 
foramen  and,  transversing  a  shallow  groove  on  the  front 
of  the  cribriform  plate,  it  passes  through  the  nasal  fissure 


^^fe&t^ 


Figure  20 
Diagram  of  the  maxillary  division  of  ihc  trigeminal  nerve. 
V.  Ganglion  scmilunare;  I.  N.  opthalmicus;  II.  N.  max- 
illaris;  III.  N.  mandibularis;  i.  N.  sphenopalatine;  2.  Rami 
alviolares  supcriores  posteriores;  3.  Ramus  alviolaris  superior 
medius;  4.  N.  infraorbitalis;  5.  Rami  palpebrals;  6.  Rami 
nasales;  7.  Rami  labiales;  8.  Rami  alviolares  supcriores  an- 
teriores;  9.  Plexus  dentalis  superior;  10.  Ramus  dcntalis  superior; 
II.  Ramus  gingivalis  superior;  a.  F.  rotundum;  b.  F.  ovale; 
c.  Canalis  infraorbitalis;  d.  Foramen  infraorbitalis;  e.  Foramina 
alviolaria  po.steriores. 

by  the  side  of  the  crista  galli  into  the  nose.  Here  it  gives 
off  a  branch,  the  internal  nasal,  to  the  mucous  membrane 
of  the  nasal  septum. 


42  ORAL   ANESTHESIA 

The  external  nasal  branch  is  given  off  with  the  internal. 
It  supplies  the  tip  of  the  nose. 

The  infratrochlear  branch  is  given  off  just  before  the 
nasociliary  nerve  passes  through  the  anterior  ethmoidal  fora- 
men and  joined  by  the  filament  of  the  supratrochlear  nerve,  it 
passes  to  the  inner  canthus  of  the  eye,  the  conjunctiva,  the 
cornea,  and  the  skin  of  the  bridge  of  the  nose. 

Maxillary  Division 

The  maxillary  nerve  emerges  from  the  foramen  rotundum. 
It  is  entirely  sensory.  It  crosses  the  pterygopalatine  fossa 
(O.  T.  sphenomaxillary  fossa)  and  enters  the  infraorbital 
groove  which  leads  into  the  canal  of  the  same  name.  Here  it 
is  called  the  infraorbital  nerve.  In  the  pterygopalatine  fossa, 
the  zygomatic  and  sphenopalatine  branches  are  given  off. 

The  zygomatic  nerve  enters  the  orbit  and  immediately 
divides  into  two  branches:  the  zygomatico- temporal  and 
zygomatico-facial.  The  first  supplies  the  skin  of  the  an- 
terior part  of  the  temple  as  well  as  the  conjunctiva  and 
lateral  part  of  the  lower  lid,  the  latter  the  zygomatic  region 
of  the  face. 

The  sphenopalatine  nerves  descend  from  the  first  part  of 
the  maxillary  nerve  to  form  the  sensory  or  short  roots  of  the 
sphenopalatine  ganglion. 

The  posterior  superior  alveolar  branches  (O.  T.  dental 
rami)  are  given  off  just  before  the  nerve  enters  the  infraor- 
bital groove.  They  are  two  or  three  in  number,  but  often  have 
a  common  trunk.  They  divide  and  pass  downward  on  the 
tuberosity  of  the  maxilla.  Filaments  ramify  to  the  buccal 
part  of  the  gum  and  mucous  membrane  of  the  cheek;  these 
are  called  the  superior  gingival  branches.  The  posterior  al- 
veolar branches  enter  from  the  infratemporal  surface  of 
the  maxilla  into  the  posterior  alveolar  canals.  They  sup- 
ply the  mucous  membrane  of  the  maxillary  sinus,  and  then 
take  part  in  the  formation  of  the  superior  dental  plexus, 


SPECIAL  AX  ATOMY  OF   THE  ORAL  CAVITY 


43 


supplying  the  molar    teeth,   the    alveolo-dental    membrane 
and  the  gum. 

The  middle  superior  alveolar  nerve  sometimes  branches 
from  the  maxillary  nerve  just  before  it  enters  the  infraor- 
bital groove.  More  frequently,  however,  it  originates  in 
the  posterior  part   of   the   canal.     It  runs   downward   and 


Figure  21 
Dissected  skull,  showing  the  anterior  superior  alveolar  canal. 

forward  on  the  outer  wall  of  the  maxillary  sinus,  in  a  special 
canal,  to  supply  the  bicuspid  teeth  and  join  in  the  formation 
of  the  superior  dental  plexus. 

The  anterior  superior  alveolar  branch  is  the  largest.  As 
a  common  trunk,  it  runs  through  a  canal  in  the  anterior  wall 
of  the  antrum;  then  divides  into  a  series  of  branches,  supply- 
ing the  incisor  teeth  and  the  cuspid  and  anastomosing  with 
the  middle  superior  alveolar  branch.     It  also  supplies  the 


44  ORAL  ANESTHESIA 

fore  part  of  the  mucous  membrane  of  the  inferior  meatus  of 
the  nose.  It  is  a  common  observation  that  by  anesthetizing 
the  mucous  membrane  of  the  nose,  the  patient  experiences 
numbness  of  the  front  teeth. 

The  superior  dental  plexus  is  formed  by  the  free  branching 
of  the  three  superior  alveolar  nerves.  Its  subdivisions  supply 
the  teeth  and  the  alveolar  process. 

The  superior  dental  rami  are  the  small  nerve  fibers  which 
enter  the  roots  of  the  teeth  by  the  apical  foramina,  to  take 
part  in  the  formation  of  the  pulps,  supplying  also  the  alveolo- 
dental  membrane. 

The  stxperior  gingival  branches  are  also  given  off  from 
the  superior  dental  plexus.  They  pass  into  the  alveolar 
process  and  supply  the  gum. 

The  infraorbital  nerve  forms  three  terminal  branches 
after  it  emerges  from  the  foramen. 

The  inferior  palpebral  branches  pass  upward  beneath 
the  orbicularis  palpebrarum  muscle  and  supply  sensory 
fibers  to  the  skin  and  conjunctiva  of  the  lower  eyelid. 

The  internal  nasal  branches  supply  the  skin  of  the  side 
of  the  nose  and  join  with  the  nasal  branches  of  the  ophthal- 
mic nerve. 

The  superior  labial  branches  are  the  most  numerous. 
They  pass  beneath  the  levator  labii  superioris  muscle  and 
are  distributed  to  the  mucous  membrane  of  the  oral  cavity 
overlying  the  anterior  surface  of  the  maxilla  and  the  integu- 
ment of  the  upper  lip. 

The  sphenopalatine  ganglion  (O.  T.  Meckel's  ganglion) 
is  deeply  placed  in  the  pterygomaxillary  fossa.  It  is  heart- 
shaped  and  lies  just  below  the  maxillary  nerve,  in  which 
it  has  two  sensory  roots.  The  motor  root  arises  from  the 
facial  nerve  and  is  called  the  large  superficial  petrosal  nerve; 
the  sympathetic  root  comes  from  the  carotid  plexus,  and  is 
called  the  deep  petrosal  nerve.  They  join  and  form  the 
Vidian  nerve.  The  following  branches  of  the  sphenopalatine 
ganglion  are  of  interest: 


SPECIAL  ANATOMY  OF  THE  ORAL  CAVITY  45 


Figure  22 
Sagittal  section  of  skull  through  median   line,  to   show  nasal 
and  palatal  branches  of  sphenopalatine   ganglion;    also  lingual 
and  buccinator  nerve. 

The  anterior  palatine  nerve  passes  through  the  palatine 
canal  emerging  from  the  palatine  foramen  and  is  accom- 
panied by  the  artery  which  supplies  the  hard  palate,  as  far 
forward  as  the  cuspid  teeth. 


46 


ORAL  ANESTHESIA 


The  middle  palatine  nerve  issues  through  the  accessory 
palatine  foramen,  supplying  the  soft  palate,  uvula,  and 
tonsils. 


Figure  23 
Diagram  of  the  sphenopalatine  ganghon  and  its  branches. 
V.  Ganghon  semilunare;  I.  N.  ophthalmicus;  II.  N.  max- 
iUaris;  III.  N.  mandibiilaris;  i.  N.  spheno-palatini;  2.  N. 
vidii;  3.  N.  petrosus  superficiahs  major  (from  N.  faciahs); 
4.  N.  petrosus  profundus  (from  carotid  plexus);  5.  N.  phar- 
yngis;  6.  N.  naso-palatinus;  7,  8.  Rami  nasales;  9.  N. 
palatinus  anterior;  10.  N.  palatinus  medius;  11.  N.  palatinus 
posterior;  a.  F.  rotundum;  b.  F.  ovale;  c.  F.  incisivum;  d. 
F.  palatinum  ma  jus;   e.   F.  palatinum  minor. 

The  naso-palatine  nerve  runs  from  the  sphenopalatine 
foramen  across  the  inside  of  the  roof  of  the  nose  until  it 
reaches  the  septum.     From  here  it  passes  downward  and 


SPECIAL  ANATOMY  OF   THE  ORAL  CAVITY 


47 


co<^ 


Figure  24 
Diagram  of  the  mandibular  division  of  the  trigeminal  nerve. 
V.  Ganglion  semilunare;  I.  N.  ophthalmicus;  II.  N.  max- 
illaris;  III.  N.  mandibularis;  i.  N.  buccinatorius;  2.  N. 
massetericus;  3.  Nn.  temporalis  profundus;  4.  N.  pterygoideus 
cxternus;  5.  N.  pterygoideus  intcrnus;  6.  N.  auricolo  tem- 
poralis; 7.  N.  alviolaris  inferior;  8.  N.  lingualis;  9.  N.  men- 
talis;  10.  N.  mylohyoideus;  11.  Ramus  dentalis  inferior;  12. 
Ramus  gingivalis  inferior;  a.  F.  mandibularis;  b.  F.  men- 
talis;   c.   F.   rotundum;   d.    F.   ovale. 


48  ORAL  ANESTHESIA 

forward  between  the  periosteum  and  the  mucous  membrane 
to  the  incisive  canal.  It  emerges  from  the  incisive  foramen, 
is  distributed  over  the  anterior  part  of  the  hard  palate,  and 
anastomoses  with  the  anterior  palatine  nerve. 

Mandibular  Division 

The  mandibular  nerve.  This  is  the  largest  of  the  three 
divisions  of  the  trigeminal  nerve  and  is  made  up  of  a  sensory 
and  a  motor  part.  Its  egress  from  the  skull  is  through  the 
foramen  ovale  and  it  immediately  branches  into  anterior  and 
posterior  divisions. 

The  anterior  part  is  made  up  almost  entirely  of  motor 
fibers.  It  supplies  the  muscles  of  mastication  and  there- 
fore is  called  the  masticatory  nerve.  A  description  of  its 
branches  foUows. 

The  masseteric  branch  passes  in  front  of  the  mandibular 
articulation  behind  the  tendon  of  the  temporal  muscle.  It 
crosses  the  sigmoid  notch  with  the  artery  of  the  same  name 
and  passes  to  the  deep  surface  of  the  masseter  muscle.  It 
also  gives  off  a  small  filament  to  the  mandibular  joint. 

The  internal  pterygoid  branch  is  in  close  contact  with 
the  otic  ganglion.  It  passes  downward  and  inward  to  the 
deep  surface  of  the  internal  pterygoid  muscle. 

The  deep  temporal  branch  passes  outward  and  upward 
above  the  external  pterygoid  muscle  and,  being  in  close  con- 
tact with  the  temporal  bone,  enters  the  deep  part  of  the 
muscle. 

The  external  pterygoid  branch  is  most  frequently  given 
off  from  the  buccinator  branch,  but  may  arise  as  a  separate 
branch  of  the  anterior  part  of  the  mandibular  nerve.  It 
supplies  the  external  pterygoid  muscle. 

The  buccinator  branch  is  almost  entirely  sensory.  It 
descends  at  the  inner  surface  of  the  coronoid  process  and 
continues  along  the  anterior  margin  of  the  ramus  until  it 
passes  into  the  cheek  at  the  level  of  the  parotid  duct.     At 


SPECIAL  ANATOMY  OF   THE  ORAL  CAVITY  49 

the  surface  of  the  buccinator  muscle  it  divides  into  a  superior 
and  inferior  branch.  The  superior  suppHes  the  upper  part 
of  the  buccinator  muscle  and  the  skin  overlying  it,  while 
the  inferior  passes  forward  to  the  angle  of  the  mouth.  It 
supplies  the  skin  and  lower  part  of  the  muscle,  the  mucous 
membrane  lining  the  inner  surface  of  the  cheek  and  the 
buccal  part  of  the  gum  in  the  lower  jaw  from  the  first  or  second 
bicuspid  back  to  the  ascending  ramus. 

The  posterior  part  of  the  mandibular  nerve  is  the  larger 
and  contains  for  the  most  part  sensory  fibers.  It  divides 
into  three  branches. 

The  auriculotemporal  nerve  arises  as  a  rule  by  two  roots 
which  pass  on  each  side  of  the  middle  meningeal  artery  and 
then  reunite.  It  then  passes  back  between  the  internal 
pter\^goid  muscle  to  the  inner  side  of  the  neck  of  the 
mandible.  From  here  it  accompanies  the  temporal  artery 
ascending  over  the  zygoma,  where  it  divides.  The  branches 
of  the  auriculotemporal  nerve  supply  principally  the  skin  of 
the  anterior  part  of  the  auricle,  and  of  the  temporal  region 
of  the  cheek,  the  external  auditory  meatus  and  part  of  the 
outer  surface  of  the  tympanic  membrane. 

The  lingual  nerve  passes  behind  the  external  pterygoid 
muscle,  together  with  the  inferior  alveolar  nerve  at  its  inner 
side.  It  soon  turns  forward  and  descends  between  the  ramus 
of  the  mandible  and  the  internal  pterygoid  muscle,  de- 
scending at  its  anterior  margin.  Finally  it  crosses  the 
submaxillary  duct  and  supplies  the  anterior  two-thirds  of 
the  tongue.  It  gives  off  branches  to  the  tonsil  and  the 
inner  surface  of  the  mandible,  being  distributed  to  the 
periosteum,  the  lingual  gum  of  the  lower  jaw,  and  the  mucous 
membrane  of  the  floor  of  the  mouth. 

The  inferior  alveolar  nerve  fO.  T.  inferior  dental)  is 
the  largest  branch  of  the  mandibular  nerve.  It  passes 
downward  with  the  lingual  nerve,  at  first  beneath  the  ex- 
ternal pterygoid  muscle,  then  is  joined  by  the  inferior  al- 


5° 


ORAL  ANESTHESIA 


Figure  25 

Lateral  view  of  face,  showing  nerve  supply  of  skin.  i.  Lachry- 
mal N.  2.  Supraorbital  N.  3.  Supratrochlear  N.  4.  Infra- 
trochlear  N.  5.  Ext,  nasal  N.  6.  Zygomatic-temp.  N.  7.  Zygo- 
matic facial  N.  8,  9,  10.  Palpepral,  nasal  and  labial  branch  of 
infraorbital  N.  11.  Buccinator  N.  12.  Auricolotemporal  N. 
13.  Mental  N.  14,  15.  Post,  and  ant.  great  auriculor  N.  16, 
17.    Sup.  and  inf.  cutaneous  Coli.  N. 

A.  Supplied  by  ist  division  of  V.  B.  Supplied  by  2d  division 
ofV.     C.   Supplied  by  3d  division  of  V.    D.   Supplied  by  cervical 


SPECIAL  ANATOMY  OF   THE  OILiL  CAVITY  51 

veolar  artery  and  enters  the  pterygo-mandibular  space 
between  the  inner  side  of  the  ramus  and  the  internal  ptery- 
goid muscle.  Both  vessels  and  nerve  enter  the  mandibular 
foramen,  behind  the  lingula  the  nerve  lying  anteriorly. 
Here  the  mylohyoid  nerve,  which  runs  with  the  artery  of 
the  same  name  along  the  mylohyoid  groove,  is  given  off. 
It  is  chiefly  motor  in  character  and  supplies  principally  the 
mylohyoid,  digastric  tensor  palati  and  tensor  tympani 
muscles.  The  inferior  alveolar  nerve  follows  the  mandibu- 
lar canal,  forming  the  inferior  dental  plexus  and  giving  off 
the  mental  branch  in  the  bicuspid  region.  The  remainder 
forms  the  incisor  branch,  which  continues  inside  the  man- 
dible, supplying  the  incisor  teeth.  The  end  branches  are 
said  to  anastomose  with  the  branches  of  the  opposite  side, 
and  some  investigators  (Biinte  and  Moral)  believe  that  they 
communicate  with  the  lingual  nerve  forming  a  loop  such 
as  is  found  in  the  upper  jaw,  where  the  alveolar  branches, 
coming  from  the  tuber  maxillare,  anastomose  with  the  an- 
terior alveolar  branches  or  the  anterior  palatine  nerve,  which 
in  turn  communicates  with  the  nasopalatine  nerve.  The 
value  of  these  anastomoses  lies  in  the  fact  that  nerve  im- 
pulses intercepted  in  one  direction  may  be  transmitted  by 
the  other  end  of  the  loop. 

The  inferior  dental  rami  enter  the  roots  of  the  teeth  to 
take  part  in  the  formation  of  the  pulp  and  also  to  supply  the 
alveolodental  membrane. 

The  inferior  gingival  rami  supply  the  alveolar  process  and 
gums. 

The  mental  nerve  is  a  branch  of  the  inferior  alveolar 
nerve.  It  emerges  through  the  mental  foramen,  and  sup- 
plies the  skin  of  the  chin,  the  corner  of  the  mouth,  and  the 
mucous  membrane  of  the  lower  lip  and  the  anterior  part  of 
the  gum,  as  far  back  as  the  first  bicuspid  tooth. 

The  otic  ganglion  is  situated  just  below  the  foramen 
ovale  and  is  in  close  contact  with  the  inner  surface  of  the 


52 


ORAL  ANESTHESIA 


mandibular  nerve.  The  long  or  sensory  root  is  the  lesser 
superficial  petrosal  nerve,  a  continuation  of  the  tympanic 
branch  of  the  glossopharyngeal  and  a  branch  from  the 
auriculotemporal  nerve.  The  motor  root  comes  from  the 
internal  pterygoid  branch  of  the  mandibular  nerve  and 
the  sympathetic  root  is  derived  from  the  plexus  around 
the  middle  meningeal  artery. 

Its  branches  are  filaments  to  the  tensor  tympani,  chorda 
tympani,  mucous  membrane  of  the  middle  ear,  and  tensor 
palati. 

The  submaxillary  ganglion  is  found  over  the  deep  part 
of  the  submaxillary  salivary  gland.  Its  sensory  root  arises 
from  the  lingual  nerve,  its  motor  root  from  filaments  received 
by  the  lingual  nerve  from  the  chorda  tympani,  a  branch  of  the 
facial  nerve  and  the  sympathetic  root  from  the  plexus  around 
the  facial  artery.  The  branches  are  distributed  to  the  sub- 
maxillary gland  and  duct  and  the  mucous  membrane  of 
the  mouth. 

The  following  tables  may  be  found  practical  for  ready 
reference  in  regard  to  the  sensory,  secondary  branches  and 
main  nerves  supplying  the  organs  and  tissues  of  the  mouth: 


Region 


Part  Supplied 


Sensory 
Branch 


Secondary 
Branch 


Main  Nerve 


I.  TEETH,  ALVEOLAR  PROCESS  AND   GUMS  OF  UPPER  JAW 


Incisor  region 


Bicuspid  and 
molar  region 


f  Teeth  and  labial  part 
[  Palatal  part 

f  Teeth  and  buccal  part 
[  Palatal  part 


Ant.  Sup.  Alveolar 
Naso-palatine 


Middle    and    post, 
sup.  alveolar 

Ant.  palatine 


Infraorbital 
Sphenopalat.   G. 


Infraorbital 
Sphenopalat.   G. 


Second    Division 
of  V. 


2.  TEETH,   ALVEOLAR  PROCESS  AND   GUMS  OF  LOWER  JAW 


Ant.  region  to  ist 
bicuspid 


Post,  region  from 
2d  bicuspid  to 
3d  molar 


[  Teeth 

i      Labial  part 

[      Lingual  part 


f  Teeth 

i      Buccal  part 

[      Lingual  part 


Inf.  alveolar 
Mental 
Lingual 

Inf.  alveolar 
Buccinator 
Lingual 


Inf.  alveolar 


Third      Division 
of  V. 


SPECIAL  ANATOMY  OF  THE  ORAL  CAVITY 


53 


Region 

Part  Supplied 

Sensory                    Secondary 
Branch                        Branch 

Main  Nerve 

3.  IXXER\"ATIOX  OF   UPPER  JAW,   MAXILLARY  SINUS,  AND  LOWER  JAW 

Upper  jaw 
Max.  sinus 

Entire 

Sup.  Alveolar 
Branches 
Nasal  branches 

Second    Division 
of  V. 

Second    Division 
of  V. 

E.xtemal  part 
Internal  part 

Infraorbital             1 
Spheno-palat.   G.   J 

Lower  jaw 

Entire  sensory 
branches 

Third      Division 
of  V. 

4.   INNERVATION  OF   P.\LATE, 

1 
CHEEKS,  TONGUE,  FLOOR  OF   MOUTH,  LIPS          | 

Hard  palate 

f  Ant.  part 
\  Post,  part 

Naso.  palatine 
Ant.  palatine 

Second    Division 
of  V. 

Soft  palate 

/  Soft  palate 
1      Uvula 

Mid.  &  post,  palat. 
Mid.  &  post,  palat. 

Spheno-palat.   G.   J 

Cheeks 

Mucous  membrane 

Buccinator 

Third      Division 

Tongue 

f  Ant.  part 
\  Post,  part 

Lingual 
Lingual  branch 

of  V. 

Third      Division 

of  V. 
Glosso- 
pharyngeal 

Floor  of  mouth 
Lips 

Lingual 

Labialis  superior 
Mental 

Third      Division 
of  V. 

Second  Division 
Third      Division 
of  V. 

/  Upper  lip 
\  Lower  lip 

Infraorbital 
Inf.  Alveolar 

S.  INNERVATION  01 

-  THE  SKIN  OF  FACE  AND   NECK 

Skin  of  outer  cantus 

Lacrimal 

Upper  lid,  forehead  and 
Crown 

Skin  of  inner  cantus 
Tip  of  nose 

Supraorbital          1 

Supratrochlear      J 

f  Infratrochlear        1 

1,  Ext.  nasal              J 

Frontal 
Naso-ciliary 

First      Division 
of  V. 

Ant.  part  of  temple 

Malar  region 

Lower  eyelid  and  ant.  part 
of  cheek 

Ala  of  nose 

Zygomaticotemp.  1 
Zygomaticofacial  J 
Palpebral 

Nasal 

Zygomatic 
Infraorbital 

Second  Division 
of  V. 

Upper  lip 

Labial 

Angle  of  mouth 

Ant.  part  of  auricle, 
temple  and  check 

Buccinator 
Auriculotemporal 

Third    Division 
of  V. 

Lower  jaw  and  chin 

Mental 

Inf.  alveolar 

Angle  of  jaw 

Ant.  branch  of  great  Auricular 

Post.  Auricular 
region 

Post,  branch  of  great  Auricular 

Cervical    Plexus 

Inf.  border  of  jaw 

Sup.  cutaneous  Coli 

Ant.  part  of  nee 

c 

Inf.  cutaneous  Co 

i 

PART  III 

INSTRUMENTARIUM 

A  LARGE  number  of  syringes  and  accessory  appliances 
for  local  anesthesia  have  been  devised  during  the  last 
few  years,  and  the  extensive  armamentarium  which  is  some- 
times illustrated  in  publications  or  exhibited  by  a  clinician 
creates  a  great  deal  of  confusion  in  the  mind  of  the  beginner. 
The  armamentarium  should  be  simple  and  adapted  for 
quick  use,  facilitating  sterilization  and  aseptic  measures. 
It  is  best  to  keep  the  entire  outfit  for  local  anesthesia  sepa- 
rately on  a  small  aseptic  glass  table. 

For  intraoral  anesthesia  the  author  uses  the  following: 
Syringe  No.  1  for  Intraoral  Injections.  The  R.  and  R. 
Fischer  syringe  made  of  metal  and  glass  is  satisfactory  for  all 
conditions.  It  is  advisable  to  keep  two  or  three  mounted 
with  the  various  needles  and  connections  in  order  to  save  time. 
The  author  uses  the  long  42  mm.  needles  for  both  methods 
and  has  two  syringes  mounted  with  these,  so  that  the  nurse 
or  assistant  can  refill  one  while  the  other  is  in  use.  This 
has  the  advantage  of  saving  time,  if  more  than  one  injection 
is  required,  and  does  away  with  moments  of  apprehension 
and  dread,  experienced  by  the  very  sensitive  patient.  The 
third  syringe  should  have  a  barrel  long  enough  to  hold 
3  cc.  and  should  be  fitted  with  the  special  bayonet  attach- 
ment designed  by  the  writer  and  a  50  mm.  needle  for  the 
sphenomaxillary  injection.  (Some  R.  and  R.  Fischer  syr- 
inges are  graduated  to  2  cc,  but  have  barrels  sufficiently 
long  to  hold  3  cc.) 

54 


INSTRUMENTARIUM  55 

Needles.  Schimmel  needles  with  short,  concave,  razor- 
edged  points  are  employed.  These  are  not  soldered  to 
the  hub,  but  are  passed  through  it,  and  when  screwed  into 


Figure  26 
Syringes  for  intraoral  mcthorls.  Tiic  small  syringe  with  27- 
gauge  platinum  needle  for  mucous  anesthesia  previous  lo  injecting 
with  the  large  syringe.  The  next  syringe  is  Fischer's  syringe, 
mounted  with  the  short  needle.  The  third  is  mounted  with  the 
45  mm.  long  needle,  and  the  last  one  is  mounted  wilh  l-'ischer's 
bayonet  piece  and  a  50  mm.  long  needle. 

the  -syringe,  the  soft  metal  cone  at  the  end  of  the  needle  is 
expanded    and   forms   a   non-lcakable   joint.      The    needles 


56  ORAL  ANESTHESIA 

are  manufactured   in   steel,  pure   nickel,   gold,  and   iridio- 
platinum. 

Steel  needles,  when  used,  should  either  be  discarded 
after  each  case  or  subjected  to  a  careful  sterilization.  When 
sterilizing,  the  needle  must  be  washed,  boiled,  alcohol 
forced  through  the  lumen,  and  dried  by  hot  air,  after  which 


Figure  27 
New  bayonet  attachment  with  50  mm.  needle. 

a  wire  should  be  drawn  through  and  the  needle  laid  in  a 
carefully  stopped  glass  vial.  This  is  important,  because  steel 
needles,  when  not  perfectly  dry,  are  apt  to  rust  and  to  break 
during  an  injection.  Iridio-platinum  needles  are  used  by 
the  writer,  as  they  may  be  bent  several  times  with  less 
danger  of  breaking,  and  if  desirable  they  can  be  slightly 
curved,  which  is  of  help  in  some  cases.  They  can  be  left 
mounted  and  are  therefore  always  ready  for  use.     Frequent 


INS  TR  UMEN  TA  RI UM 


57 


sharpening  is  of  importance,  in  order  to  minimize  the  pain 
caused  by  inserting  the  needle.  A  special  round,  fine,  engine 
stone  may  be  used  for  this  purpose.  Use  the  following 
needles  and  hubs: 


^Method  of  Anesthesia 

Length 
in  mm. 

Inches 

Metal 

Gauge 

Hub 

Infiltration  anesthesia 
Conduction  anesthesia  except 
For  sphenomaxillary  injection 

26 
42 
50 

I 
2 

I.  P. 
I.  P. 
I.  P. 

25 

25 
25 

short 
long 
long 

A  42  mm.  needle  can  also  be  had  with  extra  heavy  walls 
and  the  same  outside  diameter.  This  needle  is  considerably 
stronger  and  is  to  be  highly  recommended. 


CONTAa 
TiOHTfNIKS 


CiiUi"''^ 


'miTiils^ 


a  b 

FiGUEE   28 
Schimmel  needle  in  hub.     Shows  how  a  tight  joint  is  produced 
by  tightening  the  hub.     a.   Before  tightening  up.     b.   After  tight- 
ening up. 

Boiling  cups  are  made  in  three  sizes,  containing  3  cc,  6 
cc,  and  10  cc.  of  solution.  The  best  are  made  of  a  porcelain 
which  is  free  from  alkalies.  They  are  graduated  and  come 
with  a  wire  handle  which  serves  at  the  same  time  as  a  holder. 
Unfortunately  the  holder  corrodes  in  alcohol.  Any  dentist, 
however,  can  easily  make  a  handle  of  similar  shai)e  of  pure 
nickel  wire  or  precious  metal.  The  cups  should  be  cleaned 
occasi<'jflally  ^Tth  dilute  hydrochloric  acid. 


58 


ORAL  ANESTHESIA 


Figure  29 
Large  and  small  dissolving  cups. 


Figure  30 
Glass  jar  with  ground  cover  and  glass  tray  to  hold  syringes  and 
cups. 


INSTRUMENTARIUM  59 

A  glass  jar  with  ground-glass  cover  to  prevent  evaporation 
is  used  to  sterilize  and  keep  the  syringes  and  boiling  cups  in. 
A  new  one  has  been  perfected  recently,  which  contains  a  glass 
tray  instead  of  a  metal  stand. ^  It  has  four  holes  for  either 
two  syringes  and  two  cups  or  three  syringes  and  one  cup. 
The  cups  can  also  be  placed  on  the  top  of  the  tray  without 
the  wire  holder.  Pure  alcohol  can  only  be  purchased  if 
one  is  the  holder  of  a  special  permit,  which  is  given  on  bond, 


FlGUEE   31 

Bottle  for  Ringer  solution  and  tray  for  tablets  and  needles. 

but  it  can  be  substituted  by  the  following  formula: 

Alcohol  95  p.  c 99  parts 

PhenoUs      i  part 

Bottle  for  Ringer  Solution.  This  bottle  has  a  ground- 
glass  stopper  and  protecting  cover.  The  bottle  should  be 
marked  100  cc,  so  as  to  facilitate  the  making  of  the  solu- 
tion, which  is  described  in  the  next  chapter. 

A  glass  tray  with  cover  is  useful  for  novocain  tubes,  re- 
serve needles,  and  engine  stones  for  sharpening  needles.  A 
similar    tray   can  be   used   for  applicators.     These  are  the 

1  John  Hood  Co.,  Boston,  Mass. 


6o 


ORAL  ANESTHESIA 


regular  applicating  sticks  cut  in  half  and  wound  with  cotton 
on  one  end.  A  certain  number  should  be  prepared,  sterilized, 
and  put  in  the  container  for  applying  the  iodine  solution  to 
the  mucous  membrane. 

An  alcohol  lamp  fitted  with  protecting  shield  for  flame 
and  ring  to  hold  dissolving  cup. 


Figure  32 
Alcohol  lamp  ^vith  holder  for  dissolving  cups. 

For  extraoral  anesthesia  additional  instruments  are  re- 
quired : 

Syringe  No.  2  for  Extraoral  Injections.  A  Record,  or 
Luer  syringe  of  5  cc.  capacity  is  used.  These  have  slip 
connection  ends  and  can  be  readily  attached  after  the  needle 
has  been  inserted.  They  can  be  taken  apart  and  sterilized 
by  boiling;  but  no  soap  or  soda  solution  should  be  used,  as 
alkaloidal  reagents  decompose  the  anesthetic  solution.  The 
Record  syringe  is  made  of  glass  and  metal,  but  can  be  easily 
taken  apart  and  reassembled  without  having  to  tighten  any 
parts  by  means  of  wrenches  or  pliers.  The  Luer  syringe  is 
still  simpler,  being  made  entirely  of  glass,  but  the  nozzle 
breaks  easily. 


INSTRUMENTA  RIUM  6 1 

Needles.  An  assortment  of  steel  or  nickel  needles  fitting 
the  nozzle  of  the  syringe  should  be  kept  on  hand.  It  is  of 
advantage  to  have  a  number  of  various  gauges  and  lengths. 


Figure  33 
Record  syringe  and  needles  for  extraoraJ  methods. 

A  needle  of  22  or  23  gauge  and  6  to  8  cm.  long  answers  nearly 
all  requirements.  All  that  has  been  said  about  the  steel 
needles  for  the  intraoral  methods  applies  to  these.  (Iridio- 
platinum  recommended.) 


PART   IV 

PHARMACOLOGY   OF   DRUGS   USED   FOR   LOCAL 
ANESTHESIA 

Cocain 

A  CERTAIN  plant,  later  named  Erythroxylum  coca,  the 
leaves  of  which  were  used  by  the  natives  of  Peru  and 
Bolivia  for  overcoming  hunger  and  fatigue,  was  discovered 
by  Pizarro  in  1532.  He  observed  that  runners,  after  chewing 
the  leaves,  were  capable  of  enduring  the  fatigue  of  long 
distances  without  being  conscious  of  hunger.  He  deduced 
that  the  absence  of  the  sensation  of  hunger  was  the  result 
of  the  local  anesthetic  action  on  the  endings  of  the  sensory 
nerves  of  the  stomach,  and  that  the  prevention  of  exhaus- 
tion was  probably  due  to  stimulation  of  the  central  nervous 
system.  It  was  not  until  the  nineteenth  century  that  the 
plant  was  exported  to  Europe.  From  the  leaves  an  alka- 
loid of  the  formula  C17H24NO4  called  cocain  was  extracted, 
from  which  several  salts  were  prepared,  the  principal  one 
being  cocain  hydrochloride,  C17H24HCI.  In  1855  Garmecke 
noted  that  theleaves  when  chewed  caused  numbness  of  the 
tongue.  Von  Aure  in  1879  was  the  first  to  inject  cocain  into 
his  arm.  Soon  afterward  many  investigators  tried  a  solu- 
tion for  operations  on  the  eye,  throat,  and  nose.  Its  use 
was  more  and  more  developed  and  a  great  advance  was 
made  when  Carning  and  Goldscheider  demonstrated  that 
nerve  impulses  were  inhibited  when  cocain  was  injected  into 
a  nerve.  Cocain  gradually  came  into  general  use  and 
was  employed  in  from  one  half  to  twenty  per  cent  solu- 
tions in  all  fields  of  medicine.  Its  toxic  effects,  however, 
became  more  and  more  evident  and  many  fatal  cases  were 

62 


PHAmfACOLOGY  OF  DRUGS    USED  63 

reported  from  even  very  small  doses,  while  comparatively 
large  amounts  could  be  administered  to  others  without 
deleterious  results.  It  was  found  that  in  certain  diseases 
cocain  was  contraindicated  on  account  of  its  toxic  action 
on  the  nerves,  kidneys,  and  heart,  especially  in  anemia, 
chlorosis,  neurasthenia,  nephritis,  heart  disease,  arterio- 
sclerosis, and  in  patients  with  lowered  resistance.  These 
untoward  effects  became  a  serious  objection  to  the  use  of 
this  drug,  which  was  the  means  of  promoting  the  develop- 
ment of  a  new  method  for  the  elimination  of  pain  in  surgical 
operations.  ]\Ioreover,  its  habit-forming  property,  with 
its  sinister  sequelae  of  pathological  and  moral  degeneration, 
revealed  such  a  serious  aspect  that  even  legislative  measures 
had  to  be  invoked  to  protect  society  against  its  use.  Sci- 
entists, therefore,  endeavored  to  discover  a  drug  to  replace 
the  dangerous  cocain  and  a  number  of  comparatively  non- 
toxic local  anesthetics  were  prepared.  Prominent  among 
these  are  Alpha-  and  Beta-Eucaine,  Stovaine,  Alypin, 
Tropacocain,  Anesthesin,  Holocain,  Quinine  Urea  Hydro- 
chlorid,  and  Apothesine.  Most  of  these,  however,  have  their 
shortcomings.  Some  are  very  irritant;  others  almost  as 
toxic  as  cocain;  still  others  cannot  be  sterilized  by  boiling, 
\  or  the  anesthesia  produced  is  not  satisfactory. 

Requirements  of  a  Substitute  ^or  Cocain.  Braun,  who 
has  contributed  largely  to  the  development  of  local  anes- 
thesia, formulated  the  following  requirements  of  a  substitute 
for  cocain: 

1.  The  substitute  must  not  be  inferior  to  cocain  in  its 
anesthesia-producing  power. 

2.  It  must  be  relatively  non-toxic. 

3.  It  must  not  have  any  irritating  action  even  on  the 
most  delicate  tissue,  but  must  be  absorbed  from  the  place 
of  application,  without  causing  hyperemia,  inflammation, 
painful  infiltrates  or  necrosis. 

4.  It   must  be  possible  to  combine  the  substance  with 


ORAL  ANESTHESIA 

suprarenin  without  losing  any  of  its  potency,  and  it  should 
I  not  affect  the  suprarenin. 

5.   It  must  be  soluble  in  water  and  the   solution  suffi- 
j  ciently  stable  to  permit  sterilization  at  boiling  temperature. 

Apothesine 

The  hydrochloride  of  dimethyl-amino-propyl  cinnamate, 
called  apothesine,  is  the  most  recent  local  anesthetic.  It  is 
recommended  by  some  prominent  surgeons  and  is  said  to 
conform  with  Braun's  requirements.  The  author  has  used 
it  experimentally  in  a  few  cases,  with  fair  results.  How- 
ever, it  presents  no  advantage  over  procaine,  and  its  com- 
bination with  adrenalin  instead  of  the  synthetic  suprarenin 
is  an  objection.  The  sugar  of  milk  which  is  used  as  a  base 
does  not  preserve  the  tablet  sufficiently. 

Novocain 

The  rapid  and  general  introduction,  as  well  as  the  great 
advance  in  the  technique  and  application  of  local  anesthesia, 
is  due  in  great  measure  to  the  discovery  of  novocain,  and 
its,  application  in  combination  with  suprarenin.  Novocain 
most  nearly  approaches  the  ideal  anesthetic,  as  it  practically 
satisfies  all  the  requirements  laid  down  by  Braun. 

History  of  Production.  After  the  discovery  of  the 
anesthetic  property  of  cocain,  research  was  at  once  begun 
to  determine  its  chemical  structure  and  physiological  action, 
and  when  the  disadvantages  of  cocain  became  apparent, 
pharmacologists  and  chemists  set  out  to  produce  synthetically 
a  preparation  possessing  the  same  anesthetic  qualities,  but 
conforming  with  Braun's  requirements,  enumerated  above. 
It  was  soon  found  that  all  esters  of  aromatic  acids,  to  which 
class  cocain  belongs,  had  the  property  of  inducing  local 
anesthesia,  and  many  hundreds  of  such  esters  have  been 
prepared  and  physiologically  tested.  Einhorn  examined  a 
number  of  alkamine  esters  of  benzoic  acid  but  found  that 


PHARMACOLOGY  OF  DRUGS   USED  65 

they  produced  considerable  irritation  of  the  tissue.  He 
replaced  benzoic  acid  with  its  para-amino  derivative  and 
selected  from  a  very  large  number  of  alkamine  esters  of 
aromatic  amino  and  polyamino  acids  prepared  in  his  lab- 
oratory, the  diethyl-amino-ethanol  ester  of  p-amido  benzoic 
acid.  This  drug  conformed  so  completely  to  the  pharma- 
cological and  clinical  requirements  that  its  hydrochloride 
was  introduced  in  1905  under  the  name  of  novocain,  after 
having  been  thoroughly  tested  by  Braun,  Bieberfeld,  Bier, 
and  others.  Since  then,  its  value  as  a  local  anesthetic 
has  been  demonstrated  by  an  enormous  number  of  inves- 
tigators and  clinicians  in  all  branches  of  medicine  and  sur- 
gery. 

Procaine 

Einhorn's  diethyl-amino-ethanol  ester  of  p-amido  benzoic 
acid  is  now  manufactured  in  the  United  States  under  license 
from  the  Federal  Trade  Commission  and  the  name  "  Pro- 
caine," suggested  by  the  American  Medical  Association,  was 
adopted  as  a  general  designation  for  the  product.  Several 
manufacturers  have  been  licensed  to  manufacture  "  Pro- 
caine "  and  are  permitted  to  designate  their  brands  by  their 
respective  trade-mark  names  in  connection  with  the  name 
"  Procaine."  The  special  preparation  used  by  the  writer  and 
to  which  all  statements  made  in  this  book  pertain  is  the  one 
manufactured  by  the  H.  A.  Metz  Laboratories  and  put 
on  the  market  as  "  Novocain  "  or  "  Procaine-Metz." 

It  occurs  as  small,  colorless  and  tasteless  crystals,  soluble 
in  water  (one  part)  and  less  soluble  in  alcohol  (thirty  parts). 
It  is  also  soluble  in  glycerine  (5  parts)  at  a  temperature  of 
20°  centigrade.  Its  melting  point  is  156°  centigrade.  Its 
aqueous  solution  is  neutral  and  does  not  decompose  on 
boiling. 

Chemical  Reactions.  It  shows  the  general  alkaloid 
reactions.     Tincture  of  iodine  produces  a  brown  and  picric 


66  ORAL  ANESTHESIA 

acid  a  yellow  precipitate.  Alkalies  produce  a  white  pre- 
cipitate, which  is  soluble  in  alcohol  and  ether.  If  a  solution  of 
O.I  gram  novocain  is  mixed  with  5  cc.  of  water,  three  drops 
of  dilute  sulphuric  acid  and  five  drops  of  potassium  per- 
manganate, the  violet  color  immediately  disappears.  This 
distinguishes  novocain  from  cocain. 

Incompatibles.  Contact  with  alkalies,  their  carbonates, 
and  all  alkaloidal  reagents  should  be  avoided,  as  they  de- 
compose the  drug. 

Physiological  Properties.  It  possesses  the  same  action 
upon  peripheral  sensory  nerves  as  cocain.  The  0.25  per 
cent  solution  is  sufficient  to  completely  anesthetize  even 
thick  nerve  trunks  in  about  ten  minutes.  Locally  applied 
there  is  no  irritation,  even  if  brought  in  strongly  concen- 
trated solutions  upon  the  most  sensitive  tissue,  such  as 
the  cornea.  General  effects  upon  the  system  after  its 
absorption  are  scarcely  perceptible;  neither  the  circulation 
nor  the  respiration  suffers,  and  the  blood  pressure  is  not 
increased. 

Dosage.  The  maximum  dose  is  0.5  gram  (Fischer)  for 
subcutaneous  injections,  but  as  much  as  2  grams  has  been 
used  without  producing  symptoms.  For  dental  and  oral 
operations,  requiring  the  use  of  conduction  anesthesia,  the 
maximum  dose,  which  allows  24  cc,  or  12  syringes  full 
of  a  two  per  cent  solution,  is  seldom  reached.  Caution 
should  be  used  with  patients  with  low  blood  pressure  or 
heart  depression.  The  writer,  however,  has  used  procaine 
with  success  in  very  serious  cases  of  almost  every  descrip- 
tion, where  general  anesthetics  were  contraindicated.  Even 
cases  with  a  history  of  cocain  poisoning  have  been  suc- 
cessfully handled  with  novocain. 

Toxic  Properties.  Its  use  has  become  so  general  all 
over  the  world,  with  so  very  few  reports  of  accidents,  that  it 
may  well  be  considered  a  comparatively  safe  local  anes- 
thetic.    It  is  difficult  to  determine  its  exact  toxicity  in  man 


PHARMACOLOGY  OF  DRUGS   USED 


67 


owing  to  the  fact  that  the  production  of  general  symptoms 
depends  a  good  deal  upon  the  manner  and  method  of  ap- 
plication and  the  so-called  individual  susceptibility  to  the 
drug.  In  this  connection  it  should  be  borne  in  mind  that 
psychological  factors  as  well  as  physical  conditions  often  play 
an  important  part  in  such  cases,  and  that  it  is  extremely 
difficult  to  distinguish  between  true  toxic  reactions  and 
mental  conditions.  (See  Chapter  VI.)  The  toxic  effects 
are  generally  compared  with  those  caused  by  cocain  and 
various  investigators  differ  considerably  as  to  the  exact 
proportion.  Biberfeld  (1905)  concluded  that  novocain  was 
one  fifth  to  one  sixth  as  toxic  as  cocain.  Le  Broig  (1909) 
found  novocain  about  one  half  as  toxic  as  cocain,  while 
Piquand  and  Dreyfus  (1910)  concluded  that  novocain  was 
one  fourth  to  one  sixth  as  toxic  as  cocain.  All  these  figures 
were  obtained  by  animal  experiments  and  were  again  re- 
peated by  Roth  in  191 7.  The  following  table  is  from  his 
published  article: 


CO^ilPARATIVE  TOXICITY  OF  COCAIN  &  NOVOCAIN  IN  FROGS, 
MICE,   R.\TS,   GUINEA  PIGS,  AND  RABBITS 


Animal  used 


Frogs 
Mice 
Rats 

Guinea  pigs 
Rabbits 


Method  of 
administration 


subcutaneously 


intravenously  ^ 


Cocain 

M.L.D.  1  in 

gms.  per  Kilo 

of  body 

weight 


1. 000 
o.  100 
o.  200 
0.060 
0.07s 
0.0077 


Novocain 

M.L.D.  in 

gms.  per  Kilo 

of  body 

weight 


o.  700 
0-550 
2.000 
0.600 
0.400 
0.030 


Ratio  of 
To-xicity 
Cocain  to 
Novocain 


i.o  to  1.4 
5.5  to  1.0 
10. o  to  1.0 
10. o  to  1.0 
5.3  to  1.0 
3.9  to  1.0 


*  The  M.L.D.  is  the  amount  per  kilogram  of  body  weight  required  to  kill  within 
24  hours. 

^  Administered  under  general  anesthesia. 


68  ORAL  ANESTHESIA 

Roth  concludes  from  these  experiments,  "  that  the  relative 
toxicity  of  cocain  and  novocain  varies  and  depends  upon 
the  amount  used  in  making  the  determination,  as  well  as 
upon  the  method  of  the  administration  of  the  drugs.  For 
warm-blooded  animals  the  toxicity  of  cocain  is  from  four 
to  ten  times  greater  than  novocain;  while  for  a  cold-blooded 
animal,  the  frog,  the  toxicity  of  novocain  is  slightly  greater 
than  cocain.  A  further  experiment  proved  that  if  novo- 
cain or  cocain  is  given  intravenously  in  dilute  solution  to 
anesthetize  rabbits,  at  about  five-minute  intervals,  larger 
amounts  of  the  drugs  (i86  mgs.  per  kilo  of  body  weight) 
can  be  tolerated,  than  when  given  in  a  larger  dose  to  the 
unanesthetized  animals  (27  mgs.  per  kilo  of  body  weight)." 
This  brings  out  an  important  factor,  namely  that  the  rate 
of  the  injection,  together  with  the  concentration  employed, 
must  be  taken  into  account.  The  concentration  of  the 
drug  in  the  blood  at  any  given  time  is  therefore  of  greatest 
importance;  and  in  surface  infiltration  and  conduction 
anesthesia,  this  depends  greatly  upon  the  amount  and 
rapidity  of  absorption  from  the  tissues  into  the  general  cir- 
culation. It  is  therefore  evident  that  if  the  solution  is 
accidentally  injected  into  a  vessel,  disastrous  consequences 
may  immediately  occur.  Experiments  made  by  Levy  and 
Hatcher  show  that  the  suprarenin  which  generally  is  added 
to  the  solution  to  prolong  the  anesthetic  action  by  retarding 
absorption,  tends  to  lessen  the  toxicity  of  the  drug  to  a 
notable  degree,  for  the  same  reason. 

The  cause  of  death  from  novocain  poisoning  was  also 
investigated.  Roth  found  that  after  intravenous  injection, 
the  respiration  stopped  about  one  half  to  one  minute  before 
the  heart,  if  the  injection  was  made  slowly  (2-3  minutes). 
When  making  the  injection  rapidly,  the  animal  receiving  the 
entire  amount  in  one  fourth  to  one  half  of  a  minute,  death 
would  be  cardiac,  the  heart  stopping  under  these  conditions 
10-15    seconds    before    the    respiration    had    ceased.     The 


PHARMACOLOGY  OF  DRUGS    USED  69 

symptoms  preceding  death  are  rapid  and  weak  pulse,  ir- 
regular respiration,  often  vomiting,  chronic  convulsions 
which  may  become  violent,  and  collapse. 

Methods  of  Combating  Toxic  Effects.  On  account  of 
the  rapid  action  of  novocain  poisoning,  it  is  necessary  to 
size  up  the  situation  quickly.  In  cases  of  simple  fainting, 
in  which  the  cause  is  of  an  entirely  different  nature,  we  rarely 
have  more  serious  symptoms  than  pallor,  limpness  and 
loss  of  consciousness.  In  severe  conditions  it  is  safer  to 
assume  that  we  have  to  deal  with  real  toxic  effects.  For- 
tunately such  accidents  are  extremely  rare,  but  call  for 
immediate  action. 

Before  all,  place  the  patient  in  a  recumbent  position. 
This  is  easily  accomplished  with  the  modern  dental  chair. 
It  relieves  the  heart  considerably.  Loosen  all  tight  cloth- 
ing; direct  the  patient  to  breathe  deeply,  or  if  respiratory 
failure  is  evident,  resort  to  artificial  respiration  at  once. 
Sylvester's  method  is  best  employed,  and  every  anesthetist 
should  be  familiar  with  this  method.  In  mild  cases,  aro- 
matic spirits  of  ammonia  (15  to  20  drops)  may  be  admin- 
istered with  a  small  amount  of  water  only  to  cause  irritation 
of  the  mucous  membrane.  Better  still  is  camphorated 
Validol.  Kells  suggested  that  it  be  administered  by  drop- 
ping the  proper  dose  (7  to  8  drops)  on  sugar.  In  serious 
cases,  however,  hypodermic  medication  is  to  be  resorted 
to  at  once.  For  a  cardiac  stimulant  strychnin  sulphate 
(1/30  gr.)  may  be  administered  and  repeated  after  fifteen 
minutes  and  once  again,  later,  if  necessary.  If  there  is 
danger  of  respiratory  failure,  atropine  sulphate  (1/120  to 
1/60  gr.)  should  be  given.  These  drugs  should  be  kept  on 
hand  in  the  so-called  "  Greeley  Units,"  so  that  no  time 
is  lost  in  preparing  the  solution.  Greeley  units  are  ideal  for 
emergency.  They  consist  of  a  collapsible  tube,  containing  a 
definite  dose  of  the  drug  in  solution,  sterile  and  ready  for  in- 
jection.    The  hypodermic  needle  is  attached  and  closed  with 


70  ORAL  ANESTHESIA 

a  wire  covered  by  a  glass  tube  for  asepsis.  Camphor  in  oil/ 
1-2  cc.  hypodermically  injected,  has  lately  been  introduced 
on  account  of  its  stimulant  effect  on  both  the  respiratory 
center  and  the  heart;  it  is  also  a  sedative  and  is  anti-spas- 
modic. It  is  given  subcutaneously  and  repeated  every  half 
hour.  The  most  rapid  action,  however,  is  gained  by  adminis- 
tering by  inhalation.  Smelling  salts  and  aromatic  spirits  of 
ammonia  act  by  irritating  the  mucous  membrane,  causing  a 
reflex  action.  Engstadt  of  Minneapolis,  who  has  been  work- 
ing for  fifteen  years  on  the  problem  of  cocain  poisoning, 
recommends  ether,  which  he  believes  has  a  direct  antidotal 
effect,  as  it  is  a  directly  acting,  diffusible  cardiac  stimulant, 
stimulating  the  vasomotor  as  well  as  the  respiratory  centers. 
It  increases  blood  pressure  and  apparently  has  a  special  af- 
finity for  the  toxic  elements  of  the  diffusible  alkaloids. 
Dr.  Corbit  of  the  University  of  Minnesota  reports  that 
also  in  animal  experiments  ether  would  prevent  a  fatal  out- 
come from  the  toxic  action  of  cocain  or  synthetic  substitutes. 
Engstadt  recommends  for  best  results  administration  of 
ether  to  a  degree  of  mild  surgical  analgesia  only  or  even  less 
than  that.  It  is  important  to  give  the  ether  on  a  mask 
by  the  drop  method  so  as  not  to  exclude  the  air.  Just  a 
few  shakes  of  the  ether  bottle  on  the  mask  is  usually  enough 
to  revive  the  patient.  Coffee  should  be  given  to  all  pa- 
tients who  have  experienced  toxic  effects,  no  matter  whether 
the  condition  was  mild  or  very  serious.  Its  effect  is  almost 
that  of  an  antidote  and  its  advantage  as  a  respiratory  and 
cardiac  stimulant  lies  in  its  safety  and  lasting  quality. 

Adrenalin 
The  discovery  that  deeper  and  more  prolonged  anesthesia 
can  be  produced  by  injecting  cocain  into  an  anemic  field 
and  that  the  toxic  effects  are  greatly  lessened  was  rendered 
practical  when  the  physiological  action  of  the  extract  of 
the  suprarenal  gland  was  discovered. 

1  Park  Davis  Co. 


PHARMACOLOGY  OF  DRUGS    USED  71 

Production.  The  extract  is  gained  from  the  suprarenal 
glands  of  the  sheep  or  ox  after  the  glands  have  been  freed 
from  fat,  cleaned,  dried,  and  powdered.  The  active  prin- 
ciple occurs  as  a  white  crystalline  substance,  which  dis- 
solves readily  in  salt  solutions.  It  is  marketed  under  the 
name  of  adrenalin,  suprarenalin,  adnephrin,  epinephrin,  and 
in  England  under  the  name  of  paranephrin. 

Suprarenin  Syntheticum 

The  unstable  nature  and  admixture  of  organic  impurities 
of  the  animal  product  and  the  fact  that  it  decomposes  and 
deteriorates  A-ery  easily  gave  rise  to  the  desire  to  produce 
this  drug  synthetically  in  a  pure  form.  Such  a  product 
is  now  on  the  market  and  is  called  L-Suprarenin  syntheticum.^ 
It  has  been  thoroughly  tested  by  Biberfeld,  Abderhalden, 
and  Gushing,  and  found  to  equal  if  not  surpass  in  its  chemical 
and  physiological  properties,  qualitative  as  well  as  quanti- 
tative, the  best  substances  obtained  from  the  suprarenal 
glands.  On  account  of  its  purity,  stability  of  action,  and 
greater  durability,  it  is  far  superior  to  the  organic  drug. 

Production.  Chloracetopyrocatechol  is  transformed  by 
methylamin  into  methylaminacetopyrocatechol.  By  reduc- 
ing this  keton,  the  secondary  alcohol,  L. -Suprarenin  syn- 
theticum, is  formed. 

Chemical  Properties.  The  chemical  name  is  o-dioxy- 
phenylethanolmethylamin.     Its  formula  is: 

//CH  fOH)CH2.NH.CH3 
C«H3— OH 
-OH 

Suprarenin  synthetic  is  preferably  used  in  the  form  of 
the  bitartrate  of  suprarenin,  and  in  its  solution  is  the  most 
stable  of  all  salts.  It  is  a  white  powder,  insoluble  in  alcohol 
and  ether.  It  does  not  dissolve  easily  in  cold  or  hot  water, 
but  if  titrated  with  diluted  acids  a  clear  solution  is  easily 

'  H.  A.  Metz  Laboratories  Inc. 


72  ORAL  ANESTHESIA 

obtained.  Its  melting  point  is  207-208°  centigrade.  Even 
synthetic  suprarenin  is  very  sensitive.  Free  alkali,  air, 
light,  and  especially  heat  cause  it  to  decompose.  It 
must  be  kept  in  bottles  made  of  special  alkali-free  glass, 
and  should  not  be  exposed  unnecessarily.  In  solution  it  is 
stable  only  for  a  comparatively  short  time;  in  tablet  form 
it  keeps  practically  indefinitely  either  alone  or  in  combina- 
tion with  procaine.  The  compressed  tablets  are  preferable. 
Another  advantage  over  the  organic  adrenalin  is  that  it  may 
be  boiled  for  a  short  time  for  sterilization  without  decom- 
position. Pink  or  red  coloring  of  the  solution  is  a  sign  that 
the  drug  is  decomposed.  It  should  then  be  discarded  so 
as  to  prevent  toxic  and  irritating  effects. 

Incompatibles.  Contact  with  alkalies  should  be  avoided, 
as  they  decompose  the  drug. 

Physiological  Properties.  Its  local  action,  when  applied 
to  the  surface  of  a  mucous  membrane  or  injected  subcu- 
taneously,  is  that  of  a  powerful  hemostatic.  It  contracts 
the  walls  of  capillaries  and  smaller  blood  vessels  by  its  action 
on  the  smooth  muscle  fibers.  This  is  made  use  of  in  local 
anesthesia  to  retard  the  circulation  in  the  injected  part, 
thus  hindering  the  dilution  of  the  anesthetic  and  preventing 
too  rapid  absorption.  It  therefore  intensifies  and  prolongs 
the  anesthetic  effect  and  at  the  same  time  decreases  the 
danger  of  its  own  toxic  properties,  as  well  as  that  of  the 
anesthetic  used.  It  also  may  be  used  to  produce  a  local 
anemia,  which  permits  a  bloodless  field  of  operation. 

Its  general  action  on  the  system  when  absorbed  in  very 
small  quantities,  as  in  local  anesthesia,  is  believed  by  the 
writer  to  be  a  beneficial  and  valuable  one.  Cannon,  who 
has  undertaken  extensive  investigations,  published  in  his 
extremely  interesting  and  important  work  "Bodily  Changes 
in  Pain,  Hunger,  and  Fear"  proved  that  adrenal  secretions 
are  released  into  the  circulation  in  all  strong  emotions  and 
pain,  and  that  this  in  turn  has  a  "  purposive  "  nature  in  pre- 


PHARMACOLOGY  OF  DRUGS    USED  73 

serving  the  welfare  of  the  organism.  The  viscera  are  emptied 
of  their  blood  while  a  vasodilator  action  is  exerted  on  the 
heart,  the  brain,  and  the  lungs,  supplying  these  essential 
organs,  the  "  tripod  of  life,"  as  well  as  the  skeletal  muscles, 
abundantly  with  blood.  This  drug  has  a  remarkable  in- 
fluence on  fatigued  skeletal  muscles,  quickly  restoring  them. 
It  causes  relaxation  of  the  smooth  muscles  of  the  lungs, 
another  means  of  rendering  the  organism  more  eihcient, 
by  supplying  fresh  air  and  a  speedy  discharge  of  the  car- 
bonaceous waste.  Its  action  on  the  heart  is  of  a  stimulating 
nature,  causing  an  increase  both  in  rate  and  amplitude  of 
cardiac  contraction.  It  aids  also  in  taking  sugar  from  the 
liver's  store  of  glycogen  and  adding  it  to  the  circulation, 
where  it  is  utilized  as  a  source  of  energy,  and  in  supplying 
increased  nutrition  to  the  heart.  The  heart  may  consume,  as 
Patterson  and  Starling  have  shown,  as  much  as  four  times  the 
ordinary  amount  of  glycogen  in  extreme  cases.  On  account 
of  these  physiological  properties,  suprarenin  may  be  looked 
at  as  an  "  antidote"  for  toxic  effects  of  cocain  or  novocain. 
It  is  made  use  of  by  Crile  for  the  treatment  of  shock.  He 
advocates  its  administration  in  combination  with  a  saline 
infusion  by  inserting  the  needle  of  a  hypodermic  syringe 
filled  with  adrenalin  chloride  1:1000  into  the  rubber  tube 
near  the  canula,  injecting  one  to  two  cc.  drop  by  drop  at 
short  intervals.  Its  therapeutic  value  for  this  purpose  is 
sometimes  nothing  short  of  marvelous,  as  the  writer  had 
occasion  to  observe  in  a  desperate  case  of  surgical  shock. 

Toxic  Properties.  If  suprarenin  is  used  subcutaneously 
in  too  highly  concentrated  solutions  or  if  it  is  accidentally 
injected  into  a  vessel,  toxic  symptoms  may  appear  at  once. 
Some  individuals  also  are  more  susceptible  to  the  effects  of 
this  drug.  One  of  my  patients  gets  toxic  effects  every 
time  an  injection  of  procaine  and  suprarenin  is  administered, 
as  well  as  from  the  application  of  suprarenin  (1:1000)  alone 
to  the  mucous  membrane  of  the  nose.     Systemic  symptoms 


74  ORAL   ANESTHESIA 

attend,  as  increased  pulse  in  rate  and  volume,  blanching  of 
the  skin,  due  to  constriction  of  the  blood  vessels,  dilated 
pupils,  stimulation  of  the  secreting  glands,  causing  excessive 
flow  of  saliva,  mucous  in  the  throat,  and  marked  perspiration. 
There  may  be  slight  nausea  and  tremor  of  the  extremities. 
The  toxic  effects  of  suprarenin  are  increased  with  the  rapidity 
of  injecting,  as  has  been  proven  by  animal  experiments. 
The  most  serious  results,  however,  are  no  doubt  caused  by 
accidental  injection  into  a  small  vessel.  Stale  and  dis- 
colored solutions  are  also  more  toxic.  A  fresh  solution 
should  be  prepared  from  compressed  tablets  as  manu- 
factured by  the  Aletz  Laboratories  in  New  York.  These 
have  been  found  the  best  by  the  writer.  They  keep  for 
months  in  the  original  packing,  and  if  properly  taken  care 
of,  for  a  long  time  even  after  the  tube  has  once  been  opened. 

Dosage.  In  the  first  edition  of  this  book,  the  author 
advocated  a  reduction  of  the  percentage  of  suprarenin  in 
the  anesthetic  solution  for  normal  cases.  This  solution, 
containing  only  0.00002  gram  of  suprarenin  to  i  cc,  has 
since  then  been  used  exclusively  with  verv"  few  exceptions. 
Many  thousands  of  cases  so  treated  have  proven  that  the 
anesthesia  is  just  as  efficient  and  lasts  approximately  the 
same  length  of  time,  and  that  the  number  of  cases  with 
toxic  symptoms  has  been  reduced  to  a  minimum.  The  ex- 
periments and  observations  of  Nyman  and  Prinz  confirm 
these  findings. 

On  account  of  the  temporary  increase  of  the  blood  pres- 
sure caused  by  suprarenin  in  large  doses,  which  is  due  to  its 
stimulating  action  on  the  heart  and  the  contraction  of 
arterioles  and  capillaries,  it  is  advisable  to  use  a  weaker 
solution  and  a  smaller  amount  in  patients  with  severe  heart 
disease,  anemia,  arteriosclerosis,  and  in  old  people  with 
hardened  vessels  and  abnormally  high  blood  pressure.  In 
these  cases  use  only  o.ooooi  gram  of  suprarenin  to  i  cc. 

If  strong  local  anemia  is  desired,  the  percentage  of  supra- 


PHARMACOLOGY  OF  DRUGS   USED  75 

renin   should  be   increased  to  0.00005   gram  of  suprarenin 

to    ICC. 

Solvent  Medium 
The  principal  requirement  of  the  solution  is  that  it 
should  be  isotonic,  sterile,  and  non-irritant,  that  is.  free  from 
anv  unnecessar}-  chemicals  such  as  are  often  added  to  patent 
preparations.  Xo  antiseptics  or  preservatives  are  neces- 
sar>-.  Physiological  salt  solution  is  generally  recommended 
for  dissolving  the  anesthetic  tablets.  Some  firms  also  pre- 
pare anesthetic  tablets  containing  the  salt  required  to  make  an 
isotonic  solution.  These  are  dissolved  in  distilled  water 
only.  There  is,  however,  the  disadvantage  to  this  method 
that  the  concentration  of  the  anesthetic  solution  cannot  be 
varied  by  changing  the  amount  of  the  solvent.  The  solution 
mav  be  either  hypertonic  or  h>-potonic,  depending  on  whether 
less  or  more  distilled  water  is  used.  To  counteract  de- 
rogatory' action  of  the  glass  alkali  and  to  prevent  oxida- 
tion of  the  suprarenin,  Braun  recommends  adding  a  ver>- 
small  amount  of  dilute  hydrochloric  acid  to  the  solution. 
His  formula  is: 

Sodii  chloridi  puriss      2.0 

Acidi  hydrochlorid.     Diluti gtt.i 

Aquae  dest 300.0 

Guerber  found  that  the  addition  of  calcium  salts  greatly 
improves  the  process  of  absorption  in  the  tissue;  it  has  a 
stimulating  action  on  the  leucocytes,  which  in  turn  increase 
the  resistance  to  infection.  At  his  instigation,  Fischer 
recommended  the  use  of  the  Ringer  solution.  This  is  made 
up  as  follows: 

Sodium  chloride 0-5° 

Calcium  chloride 0.04 

Potassium  chloride 00^ 

Aquae  dest 100  00 


76 


ORAL  ANESTHESIA 


Ringer  tablets  can  be  bought  conveniently  put  up. 
Dissolve  ten  tablets  in  loo  cc.  of  distilled  water,  as  described 
below. 


Figure  34 
Femel  apparatus  to  produce  distilled  water. 


PHARMACOLOGY  OF  DRUGS   USED 


77 


Distilled  Water.  Unfortunately,  it  is  almost  impossible 
to  secure  freshly  prepared,  pure,  and  sterile  distilled  water. 
If  it  is  left  to  stand  a  few  days,  growths  of  all  kinds  of  fungi 
and  their  products  may  be  found.  Vegetations  of  these  can 
be  seen  by  the  naked  eye  swimming  around  the  container, 
and  although  the  organisms  are  killed  when  the  solution  is 


Condensing  Cfiamber 


Cooling  water  inlet 


Cooling  -water  outlet 


Figure  35 
Diagram  showing  how  Femcl  Still  works. 

boiled,  the  dead  cells  and  their  toxins  are  not  eliminated  by 
this  process.  Clinically,  this  was  demonstrated  by  Ehrlich, 
who  found  that  infusions  of  salvarsan  made  with  commercial 
distilled  water,  caused  toxic  effects  which  did  not  occur  if 
sterile,  freshly  distilled  water  was  used.  Any  one  can  easily 
produce  sterile,  toxin-free  and  chemically  pure  distilled 
water,  by  means  of  a  glass  still,  parts  of  which  can  be  bought 
at  any  supply  house  dealing  in  chemical  apparatus.     Various 


78 


ORAL  ANESTHESIA 


Figure  36c 
A  simple  home-made  still.     A.   Inlet  for  cooling  water.   B.   Outlet. 


'^^^'j  \    ^.  a  ^ 


^ 


^^ 


Figure  366 
Kells  still.  A.  Container  for  tap  water.  B.  Tube  con- 
necting with  condenser.  C.  Condenser.  E.  Cooling  coil. 
D.  Final  container.  F.  Bunsen  burner.  G.  Gas  pipe.  H. 
Water  pipe.  h.  Water  faucet.  K.  Water  reservoir.  L. 
Tube   connecting    K  with  A.     N.   Overflow,    n.  Water  outlet. 


PHARMACOLOGY   OF   DRUGS    USED  79 

types  are  made.  It  is,  however,  important  that  it  be  made 
entirely  of  glass.  The  distilled  water  should  not  come  in  con- 
tact with  metal.  The  "  Femel  still "  which  is  used  by  the 
author  is  illustrated  to  explain  the  principle  and  the  modus 
operandi.  A  vessel  filled  with  tap  water  or,  better  still,  com- 
mercial distilled  water  is  fitted  with  a  rubber  stopper  con- 
taining a  glass  tube.  This  leads  to  the  condenser,  which  may 
have  any  form  and  is  surrounded  by  a  cooling  chamber, 
through  which  cold  water  can  be  forced  in  an  opposite 
direction  to  the  steam.  The  outlet  of  the  condenser  is  con- 
nected by  a  glass  tube  wath  a  bottle  which  receives  the  dis- 
tilled water.  It  should  have  a  hood  to  protect  the  opening 
of  the  bottle  while  the  still  is  in  operation.  Figure  35  shows 
a  schematic  drawing  of  the  Femel  apparatus.  The  simplest 
form  of  a  still  for  small  quantities  is  illustrated  in  Figure  36a. 
This  can  easily  be  made  wdth  glass  tubes  and  rubber  stoppers 
by  any  one. 

The  still  is  operated  in  the  following  manner:  Set  up  the 
apparatus  and  connect  the  various  parts.  Heat  the  water 
and  let  the  steam  pass  through  the  condenser  into  the  re- 
ceiving bottle.  This  bottle  should  be  the  final  container. 
It  should  be  cleaned  previously  as  should  all  other  parts  and 
dealkalied  by  the  use  of  dilute  hydrochloric  acid.  Let  steam 
pass  through  the  apparatus  for  five  to  ten  minutes  for  ster- 
ilizing purposes  and  then  turn  on  the  cooling  water.  This 
will  condense  the  steam  entering  the  condensing  chamber 
and  the  distilled  water  will  run  into  the  bottle  into  which 
10  Ringer  tablets  are  placed.  The  bottle  is  graduated  and 
when  it  is  filled  to  the  100 cc.  mark,  the  apparatus  is  dis- 
connected and  the  bottle  closed. 

Figure  366  shows  the  Kells  still.  It  is  operated  on  the 
same  principles,  but  has  some  ingenious  accessories.  A  indi- 
cates the  bottle,  filled  with  tap  water.  This  is  continuously 
fed  from  a  reservoir,  K,  into  which  the  water  flows  from  the 
faucet.     It  is  kept  at  a  certain  level  by  means  of  the  overflow, 


8o  ORAL  ANESTHESIA 

N.  The  steam  from  the  vessel,  A,  is  conducted  into  the  con- 
denser, which  contains  a  coohng  coil,  and  from  here  it  drops 
into  the  final  container.  There  are  two  automatic  shut-offs, 
which  are  not  absolutely  necessary,  but  one  or  the  other  can 
be  used  according  to  the  conditions  under  which  the  still  is 
operated.  The  first  one  is  connected  with  the  final  container 
and  automatically  shuts  off  the  gas  underneath  the  container, 
A,  when  the  bottle  is  full  of  distilled  water.  This  is  accom- 
plished in  the  following  manner: 

When  the  bottle,  D,  is  full,  its  weight  is  counterbalanced 
by  the  weight,  X,  which  releases  the  gas  shut-off,  g.  A  similar 
contrivance  may  be  used  in  connection  with  the  reservoir,  K. 
This,  however,  is  only  necessary  in  localities  where  the  tap 
water  is  liable  to  be  cut  off  without  notice.  The  arrangement 
causes  the  gas  to  be  shut  off  at  g'  if  the  water  in  the  reser- 
voir, K,  is  emptied  and  not  replenished. 

The  whole  unit  makes  possible  the  production  of  distilled 
water  without  supervision. 


Procaine-Suprarenin  Combined 

Procaine-suprarenin  solution  may  be  prepared  in  various 
ways.  The  simplest  methods  are,  however,  not  always  the 
best  and  nothing  is  of  greater  importance  than  to  be  sure  that 
the  anesthetic  provided  is  fresh,  non-toxic  and  safe. 

Ampules  cgntaining  prepared  solutions  of  procaine  and 
suprarenin  are  in  the  market.  It  is  only  necessary  to  break 
the  end,  insert  the  needle,  and  draw  the  contents  into  the 
syringe.  However,  there  are  objections;  it  is  difficult  to 
know  the  age  of  these  solutions,  and  procaine  and  suprarenin 
do  not  keep  as  well  in  solution  as  in  tablet  form.  The 
solutions  from  ampules  are  often  badly  discolored  and  the 
question  as  to  the  sterility  of  the  solution  may  be  raised. 
Most  solutions  which  come  in  ampules  contain  antiseptics, 
such  as  thymol,  carbolic  acid,  and  others  which  are  equally 


PHARMACOLOGY  OF   DRUGS    USED  8i 

harmful,  because  they  are  irritants  and  often  are  the  cause 
of  pain,  edema,  and  necrosis. 

Prepared  Solutions.  Solutions  put  up  in  bottles  are  still 
more  undesirable  than  those  in  ampules.  After  the  bottle 
is  once  opened,  the  remainder  of  the  solution  deteriorates 
quickly.  To  overcome  this,  manufacturers  again  add  anti- 
septics. These,  besides  being  harmful,  will  only  protect 
the  drug  from  bacterial  deterioration  while  most  of  the 
toxic  properties  come  from  chemical  decomposition  due 
to  the  effects  of  light,  air,  and  heat. 

Seidel's  Method.  Seidel  makes  up  a  sterile  2  per  cent 
novocain  solution  in  large  quantity  which  he  keeps  on  hand. 
From  this,  he  measures  out  as  much  as  he  requires  and  adds 
to  it  by  means  of  a  special  normal  pipette  as  many  normal 
drops  of  suprarenin  solution  as  required.  While  this  method 
no  doubt  is  almost  ideal,  allowing  changes  in  the  dose  of  supra- 
renin for  every  case,  it,  nevertheless,  has  its  disadvantages. 
The  sensitiveness  of  the  suprarenin  solution  to  external  influ- 
ences, especially  if  not  used  frequently,  is  perhaps  the  greatest 
objection.  It  causes  considerable  waste,  as  the  remainder 
of  the  solution  cannot  be  used  very  long  after  the  bottle 
has  once  been  opened.  The  danger  of  toxic  effects  is  in- 
creased, and  if  the  solution  has  to  be  prepared  by  the  ofhce 
assistant,  there  is  the  additional  possibility  of  errors  which 
may  have  serious  results. 

Tablets,  Author's  Method.  Procaine  and  suprarenin  keep 
best  if  combined  in  tablet  form.  In  the  tablets  the  two 
ingredients  are  mixed  in  a  dry  state,  in  which  they  are  better 
pre.served.  They  do  not  deteriorate  as  long  as  no  moisture 
penetrates  into  the  tube,  which  is  prevented  by  the  use  of  a 
rubber  stopper.  The  best  tablets  are  the  compressed  kind, 
as  they  are  not  as  hygroscopic  as  the  ones  with  sugar  of 
milk  as  a  base.  The  latter  are  of  soft  consistency  and  are 
easily  spoiled. 

The  following  tablets  are  used  by  the  author: 


82  ORAL  ANESTHESIA 

T  Tablets  ^ 

Procaine-Metz 0.02       gram 

L-Suprarenin  synthetic  ....  0.00002  " 
These  tablets  are  used  in  all  normal  cases,  for  purely 
dental  as  well  as  oral  surgical  operations;  infiltration  as  well 
as  conduction  anesthesia.  Dissolve  one  tablet  to  each  cc. 
of  Ringer  solution,  which  gives  a  2  per  cent  solution  of  pro- 
caine with  0.00002  gram  of  suprarenin  to  each  cc. 

H  Tablets^ 

Procaine-Metz 0.06       gram 

L-Suprarenin  synthetic    ....   0.00006     " 
The  H  tablets  contain  the  same  proportions  of  the  drugs, 
but  three  times  the  quantity  in  a  single  T  tablet.     Dissolve 
I  tablet  in  3  cc.  of  Ringer  solution,  which  gives  the  same  pro- 
portions as  in  the  above. 

E  Tablets^ 

Procaine-Metz .0.02       gram 

L-Suprarenin  synthetic  ....  0.00005  " 
These  are  used  to  produce  local  anemia,  which  is  some- 
times desirable  to  get  a  bloodless  field  of  operation.  One 
tablet  to  each  cc.  of  the  solvent  medium  is  used,  giving  a 
solution  which  contains  2  per  cent  novocain  and  0.00005 
gram  suprarenin  to  each  cc. 

Mixing  Tablets  ^ 
In  abnormal  cases,  where  it  is  desirable  to  further  de- 
crease the  amount  of  suprarenin,  as  in  serious  cardiac  dis- 
orders, arteriosclerosis  and  anemia,  i  F  and  2  T  tablets  may 
be  dissolved  in  4I  cc.  of  Ringer  solution.  F  tablets  contain 
0.05  gram  of  procaine  and  no  suprarenin.  The  percentage 
of  the  latter  is  therefore  decreased  by  using  this  combi- 
nation, which  results  in  a  solution  containing  2  per  cent  of 
novocain  and  about  o.ooooigram  of  suprarenin  to  i  cc. 

^  H.  A.  Metz  Laboratories,  Inc.,  122  Hudson  St.,  New  York,  N.  Y. 


PHARMACOLOGY  OF    DRUGS    USED  '  83 

One  E  and  one  F  tablet  dissolved  in  3^  cc.  Ringer  solu- 
tion may  be  used  if  T  tablets  are  not  at  hand  and  give  ap- 
proximately the  same  solution. 

Procaine  Pliiglets 
These  are  used  for  pressure  anesthesia  for  the  removal 
of  the  dental  pulp  as  well  as  for  application  to  the  mucous 
membrane,   previous   to   inserting   the   needle.     They   come 
twenty  in  one  original  tube,  each  containing  the  following: 

Procaine-Metz o.oi     gram 

L-Suprarenin  synthetic    ....   0.0002     " 

Method  of  Preparing  the  Solution 

Take  syringe  and  dissolving  cup  from  jar  and  remove 
all  traces  of  alcohol  by  washing  the  cup  with  sterile  distilled 
water  and  drawing  it  into  the  syringe  a  few  times. 
Rid  the  cup  of  water  and  expel  water  from  the  syringe 
as  well  as  possible.  Measure  the  amount  of  Ringer  solution 
into  the  graduated  cup  and  add  a  little  more  to  make  up 
for  evaporation.  Place  cup  into  the  holder  over  the  alcohol 
flame,  and  when  it  comes  to  boiling  point  add  the  tablets  as 
required  to  get  the  proper  solution.  Do  not  touch  the  tablets 
with  your  hand  nor  with  instruments,  but  hold  the  tube  over 
the  cup  and  allow  them  to  roll  into  the  solution  by  turning 
the  tube  gently  and  guiding  them  with  the  rubber  stopper. 
The  latter  should  be  replaced  as  soon  as  the  tablets  are 
removed.  Heat  carefully  until  the  tablets  are  dissolved, 
letting  the  solution  boil  up  once  or  twice  for  the  purpose  of 
additional  sterilization.  Do  not  boil  the  solution  for  more 
than  a  few  seconds  after  the  tablets  have  been  added,  or 
else  the  drugs  will  decompose.  Sterilize  the  needle  in  the 
flame  and  insert  it  into  the  cup;  draw  the  piston  way  back 
and  if  the  point  of  the  needle  is  continuously  submerged, 
the  syringe  will  fill  itself  comi)letely  without  drawing  in  air 
bubbles. 

'  H.  A.  Metz  Lal>oratories,  Inc.,  122  Hudson  St.,  New  York,  N.  Y. 


84  ORAL  ANESTHESIA 

The  syringe  is  now  ready  for  use.  Place  it  so  that  the 
asepsis  of  the  needle  will  not  be  spoiled  and  cover  the  solution 
remaining  in  the  cup  with  a  glass  cover.  After  injecting, 
expel  what  is  left  in  the  syringe,  sterilize  needle  in  flame, 
wash  cup  with  sterile  distilled  water,  and  draw  same  into 
syringe  to  remove  all  traces  of  salt,  which,  if  left  in  the 
syringe,  will  spoil  the  accurate  fit  of  the  piston  in  the  barrel. 
Draw  a  small  amount  of  alcohol  into  the  syringe  and  place 
it  back  in  the  jar.  The  alcohol  in  the  jar  should  cover  the 
syringes  entirely. 

Requirements  of  a  Solution  Prepared  from  Tablets 

1.  It  should  be  used  immediately  after  it  has  been  pre- 
pared. The  fresher  a  procaine-suprarenin  solution,  the  less 
is  its  toxicity  and  the  greater  its  anesthesia-producing  power. 

2.  The  tablets  should  not  be  touched  with  hands  but 
with  instruments,  and  immediately  after  use  the  tube  should 
be  closed  with  the  rubber  stopper.  The  tablets  are  chemi- 
cally changed  by  air,  light,  and  especially  by  moisture.  The 
tablets  should  be  white.  Sometimes  the  uppermost  one  in 
the  tube  is  discolored,  caused  by  improper  handling  of  the 
tube.     Discard  discolored  tablets. 

3.  The  solution  should  not  come  in  contact  with  any- 
thing except  the  porcelain  cup  and  the  syringe.  It  should 
not  be  left  longer  than  absolutely  necessary  in  either,  as  it 
is  very  sensitive,  being  affected  and  chemically  changed  by 
air,  heat,  light,  and  especially  by  alkalies.  In  ten  minutes 
a  procaine-suprarenin  solution  will  show  discoloration.  Its 
power  then  is  diminished  and  its  toxicity  increased.  Yellow 
discoloration  is  due  to  oxidation  of  the  novocain  and  red 
discoloration  to  the  suprarenin. 


PART   V 

PREPARATION    OF   THE   PATIENT 

THE  attitude  of  the  operator  towards  the  patient  is  of 
utmost  importance,  as  has  already  been  pointed 
out  in  the  opening  chapter  of  the  book;  and  the  same  ap- 
plies to  any  other  person  with  whom  the  patient  comes  in 
contact,  either  before  or  during  the  operation.  Even  the 
arrangement  of  the  operating  room  or  the  outlook  from  the 
window  may  be  a  great  help  in  distracting  the  patients' 
thoughts,  occupying  their  minds  with  something  else  during 
a  period  w^hen  they  are  most  apprehensive.  The  same 
result  may  be  gained  by  engaging  the  patient  in  conver- 
sation which  is  of  special  interest  to  him.  If  new  pa- 
tients are  treated,  one  should  inquire  without  disturbing 
their  confidence  whether  they  have  had  local  anesthetics 
before,  and  as  a  rule  they  will  at  once  voluntarily  mention 
any  disagreeable  experiences  which  they  have  had  or  serious 
disorders  or  diseases  from  which  they  may  be  suffering.  The 
operator  can  then  be  guided  accordingly.  Change  the  per- 
centage of  the  suprarenin  if  it  seems  indicated,  and  most  of  all 
assure  the  patient  of  the  safety  and  success  of  the  operation. 

Emotional  factors  are  of  importance  and  the  natural  fear 
which  almost  every  individual  has  should  be  counteracted 
by  the  kind  and  sympathetic,  but  firm  and  assuring,  attitude 
of  the  operator.  Calm  and  decided  action  and  confidence 
on  the  ])art  of  the  operator  make  decidedly  for  success. 

No  special  preparation  is  required  as  far  as  dietary 
measures  are  concerned.     The  patient  should   be  as  little 

8s 


86 


ORAL  ANESTHESIA 


disturbed  in  his  living  habits  as  possible.  A  good  night's 
rest  and  a  cup  of  coffee  with  a  light  breakfast  are  especially 
recommended,  if  the  operation  to  be  performed  is  of  a  more 
serious  character. 


Preanesthetic  Medication 

Apprehensive,  excitable,  nervous  and  timid  patients, 
as  well  as  children,  can  sometimes  be  better  taken  care  of 
by  the  use  of  preanesthetic  medication.  Bromural- Knoll 
(a-monobrom-isovaleryl-urea),  which  is  bought  in  the  original 
tubes  containing  ten  tablets  of  5  grams  each,  is  an  excellent 
nerve  sedative  and  a  safe  hypnotic.  It  exerts  a  selective 
action  on  the  cerebrum  and  is  devoid  of  secondary  and 
injurious  effects,  even  if  given  in  overdose.  It  has  no  cumu- 
lative action,  no  habit-forming  quality,  produces  no  gastric 
irritation  and  has  no  harmful  effect  when  given  to  patients  with 
heart  disease.  It  removes  such  sensations  as  restlessness, 
anxiety,  giddiness,  and  palpitation.  Bromural  also  de- 
creases the  activity  of  the  secretory  organs,  inhibiting  bron- 
chial mucous  secretions  and  lessening  excessive  perspiration. 
The  writer  has  had  excellent  results  from  the  use  of  this  drug 
in  excitable  and  unmanageable  children,  as  well  as  neurotic 
adults.  The  dose  is  i^  grains  for  infants,  5  grains  for  chil- 
dren under  ten  years,  5  to  10  grains  for  children  over  ten 
years,  according  to  the  seriousness  of  the  operation,  and  for 
adults  10  to  15  grains.  The  tablets  must  not  be  masticated 
but  allowed  to  disintegrate  in  water.  Administer  twenty 
minutes  before  making  the  injection. 

Veronal,  a  more  powerful  hypnotic,  is  useful  when  given 
the  night  before  the  operation,  to  assure  a  good  night's  rest. 
The  dose  is  5  to  10  grains.  It  may  cause  depression  of 
respiration  and  circulation. 

Morphia.  If  the  operation  is  of  a  very  serious  nature, 
in  which  case  extraoral  injections  are  generally  used,  morphia 
may   be   resorted  to.     This  must  be  given  at  least   thirty 


PREPARATION   OF   THE   PATIENT  87 

minutes  before  the  injection  is  made,  or  else  it  should  be 
omitted  entirely,  because  in  the  beginning  its  action  is  often  of 
an  exciting  rather  than  a  quieting  nature.  The  dose  is  1/6 
to  14  gr.  subcutaneously  administered.  In  alcoholics  and 
very  strong  muscular  men  give  morphia  1/4  and  scopolamin 

i/i  so- 
Local  Preparation 

The  patient  should  be  made  comfortable  in  the  chair. 
A  partly  reclining  position  is  the  best  suited.  Tight  clothing 
should  be  loosened  to  allow  free  and  easy  circulation.  All 
instruments  should  be  prepared  and  covered  with  a  sterile 
towel  before  admitting  the  patient.  The  patient  should  not 
be  disturbed  by  the  sight  of  instruments  or  unnecessary 
sounds. 

Preparing  the  Mucous  Membrane.  Spray  the  mouth 
with  a  mild  antiseptic  solution  of  pleasant  taste,  after  which 
the  lip  or  cheek,  as  the  case  may  be,  should  be  retracted  from 
the  gum  and  tincture  of  iodine  or  a  mixture  of  tincture  of 
aconite  and  iodine,  ec^ual  parts,  applied  to  the  place  where 
the  needle  is  to  be  inserted.  Tincture  of  iodine  is  used  for 
its  well-known  antiseptic  properties,  and  the  tincture  of 
aconite  is  added  on  account  of  its  analgesic  properties.  In 
very  sensitive  patients,  the  region  may  be  superficially 
anesthetized  by  the  use  of  campho-phenique,  application 
of  procaine  crystals  or  pluglets,  or  by  a  submucous  injection 
of  a  few  drops  of  procaine  solution  made  with  a  small  hypo- 
dermic syringe,  and  a  very  sharp,  fine  (28-gauge)  iridio- 
platinum  needle. 

Preparing  the  Skin.  Extraoral  injections  must  be  made 
under  strictly  aseptic  conditions,  and  must  not  be  under- 
taken by  those  who  are  not  familiar  with  aseptic  surgical 
procedure.  The  skin  should  be  prepared  by  painting  with 
tincture  of  iodine,  covering  a  large  area.  It  is  important 
that  the  skin  be  dry  to  secure  the  best  action  of  the  iodine. 
Washing  and  shaving  should  be  done  the  day  before  and  in 


88  ORAL  ANESTHESIA 

emergency  cases  it  is  better  to  shave  dry  and  refrain  from 
washing.  Dehydrants,  such  as  ether  or  alcohol,  are  not 
necessar}'  and  only  tend  to  decrease  the  efficiency  of  the 
iodine.  After  the  operation  the  iodine  may  be  washed  off  with 
ether  or  alcohol.  The  ethyl  chlorid  spray  may  be  applied 
after  the  skin  has  been  thoroughly  prepared  to  decrease  the 
pain  from  inserting  the  needle.  However,  this  is  as  a  rule 
not  necessary  with  preanesthetic  medication. 


PART   VI 

SPECIAL   TECHNIQUE    OF   LOCAL   ANESTHESIA 

FRO]\I  the  various  methods  of  local  anesthesia,  the 
following  only  may  be  used  for  operations  in  and  about 
the  oral  cavity : 

Absorption  or  surface  anesthesia, 

Infiltration,  terminal  or  peripheral  anesthesia, 

Conduction  anesthesia  or  nerve  blocking. 

The  method  should  be  chosen  with  consideration  for 
anatomical  possibilities,  pathological  changes,  the  size  of 
the  field  of  operation,  and  the  time  required.  To  the  solu- 
tion used  for  conduction  anesthesia,  it  is  advisable  to  add  a 
certain  percentage  of  suprarenin  in  order  to  secure  a  blood- 
less field  of  operation.  In  general,  it  is  advisable  to  select  a 
method  which  covers  the  operative  field,  with  as  few  in- 
jections as  possible.  Injection  into  a  pathological  field 
should  be  avoided,  especially  if  suppuration  be  present, 
as  infection  might  be  carried  into  healthy  tissue.  It  is  a 
principle  in  modern  methods  to  separate  the  induction  of 
local  anesthesia  from  the  operation  proper.  The  interval 
which  is  necessary  for  the  anesthesia  to  deepen  can  be  util- 
ized in  making  necessary  preparations  for  the  operation, 

ABSORPTION    ANESTHESIA 

This  method  is  accomplished  by  the  application  of  local 
analgesics,  or  anesthetics,  to  the  surface.  Its  efficiency 
depends  entirely  upon  the  absorptive  qualities  of  the  tis- 
sues to  be  desensitised.  As  the  areas  affected  are  generally 
superficial,   the   usefulness  of    surface   anesthesia  is  limited, 

80 


90  ORAL  ANESTHESIA 

and  a  greater  concentration  of  the  solution  is  necessary  with 
the  method.  When  absorption  anesthesia  is  indicated  it  is 
necessary  to  guard  against  dilution  of  the  anesthetic  by  the 
action  of  the  saliva.  The  mucous  membrane  should  first  be 
thoroughly  dried.  This  method  gives  better  results  when  it 
is  possible  to  use  pressure,  as  shown  by  the  ease  with  which 
an  exposed  dental  pulp  can  be  completely  anesthetized. 

Applications  to  the  Oral  Mucous  Membrane.  Sufficient 
anesthesia  can  be  secured  for  the  painless  fitting  of  bands, 
the  finishing  of  fillings  at  the  cervical  margin,  the  application 
of  a  rubber  dam  clamp  high  up  on  the  root  of  a  tooth,  the 
lancing  of  a  subgingival  abscess,  and  the  insertion  of  the 
needle  for  hypodermic  injections. 

Preparing  the  Site  of  Application.  The  utmost  care 
should  be  taken  to  exclude  saliva  by  isolating  the  part  to 
which  the  application  is  to  be  made.  For  this  purpose 
cotton  rolls  and  napkins  may  be  used  and  the  part  swabbed 
with  a  pellet  of  cotton. 

Drugs.  Various  drugs  having  more  or  less  anesthetic 
action  may  be  used,  allowing  3  to  5  minutes  to  take  effect. 

Tincture  of  aconite.  This  is  generally  used  with  equal 
parts  of  tincture  of  iodine,  and  applied  to  the  mucous  mem- 
brane before  inserting  the  needle.  Aconite  has  a  marked 
local  anesthetic  action. 

Procaine  Solution  10-20%.  This  can  be  applied  on  small 
cotton  pellets  to  the  previously  dried  surface  of  the  mucous 
membrane. 

Procaine  Crystals  or  Powder.  Procaine  crystals  or  plug- 
lets  may  be  applied  to  a  small  area  of  the  mucous  membrane 
and  allowed  to  dissolve  in  the  moisture  of  the  tissues.  While 
waiting  for  them  to  take  effect  proper  care  is  necessary  to 
prevent  the  procaine  from  being  washed  away  by  the  fluids 
of  the  mouth. 

Method  of  Application.  An  applicator  made  by  winding 
cotton  around  the  end  of  a  toothpick  may  be  used.     Some- 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  91 

times,  however,  it  is  more  practical  to  saturate  a  pellet  of 
cotton  and  apply  it  to  the  mucous  membrane  for  a  few 
minutes.  The  absorptive  qualities  of  the  mucous  mem- 
brane can  be  increased  by  drying  with  compressed  air. 

Nasal  Application.  This  method  of  anesthetizing  the 
upper  incisor  is  often  of  value,  especially  in  the  treatment 
of  children,  who  object  to  the  pain  caused  by  the  insertion 
of  the  needle.    The  method  is  in  general  use  for  nasal  opera- 


tions. 


Drugs.  A  five  or  ten  per  cent  solution  of  cocain  is  often 
used;  but  a  20  per  cent  solution  of  procaine,  made  by  dis- 
solving 4  F  tablets  to  each  cc.  of  Ringer  solution  is  safer 
and  just  as  effective. 

^  Method  of  Application.  A  piece  of  cotton  saturated 
with  the  anesthetic  solution  is  placed  into  the  inferior  meatus 
of  the  nose,  directly  behind  the  nares.  In  a  short  time  the 
solution  will  penetrate  the  mucous  membrane  and  infiltrate 
the  bone  directly  above  the  apices  of  the  incisor  teeth.  The 
nerves  leading  to  them  are  consequently  anesthetized,  mak- 
ing it  possible  to  operate  on  these  teeth  without  causing 
pain. 

Application  to  Exposed  Pulp.  In  1890  Edward  C. 
Briggs  of  Boston  described  a  new  method  of  devitalizing 
a  tooth  with  cocain,  which  has  proven  so  satisfactory  that  it 
is  still  in  use.  It  is  generally  known  as  "pressure  anes- 
thesia "  and  if  used  properly  it  anesthetizes  the  dental  pulp  in 
a  very  short  time.  The  patient,  however,  experiences  a 
considerable  amount  of  pain  during  the  application,  on 
account  of  which  anesthesia  produced  by  injecting  is  usually 
more  satisfactory.  If,  however,  complete  anesthesia  of 
the  pulp  cannot  be  gained  by  the  infiltration  or  conduction 
method,  pressure  anesthesia  may  be  used  in  addition  with 
splendid  results,  and  with  but  little  discomfort,  on  account 
of  the  partial  numbness  already  existing. 


92  ORAL  ANESTHESIA 

Drugs  used.  Originally  cocain  pellets  were  used.  They 
are  small  compressed  cylinders,  containing  1/12  grain  of 
pure  cocain  hydrochlorid  in  soluble  form.  Similar  pellets 
are  now  used  containing  o.oi  gram  of  procaine  with  0.0002 
gram  suprarenin  and  are  just  as  efficacious.  Ordinary 
h3;podermic  tablets  such  as  recommended  for  use  in  solu- 
tion cannot  be  used  for  this  purpose  because  they  do  not 
dissolve  readily,  being  purposely  made  to  dissolve  only 
when  heated. 

Method  of  Application.  The  following  method  has  been 
found  satisfactory  by  the  writer  and  with  the  exception  of 
slight  changes  in  technique  is  the  one  in  general  use.  Apply 
the  rubber  dam,  adjusting  it  carefully  so  that  there  is  no 
leakage  around  the  tooth.  It  is  necessary  to  have  a  cavity 
with  four  walls  so  as  to  confine  the  solution  under  pressure. 
Where  four  walls  are  not  standing  they  can  be  built  tem- 
porarily, with  cement.  Before  applying  the  anesthetic 
the  adjoining  teeth  and  especially  the  cavity  should  be 
thoroughly  sterilized  by  some  germicidal  agent,  such  as  a 
solution  of  1:500  of  bichloride  of  mercury.  (This  solution 
attacks  instruments  and  pliers,  which  therefore  should  be 
coated  with  wax  or  immediately  dried.)  Dry  the  cavity 
as  well  as  possible,  and  apply  one  half  pellet  of  pro- 
caine. It  is  of  great  advantage  to  have  a  concentrated 
solution;  therefore  the  pellet  should  be  permitted  to  dis- 
solve in  the  exudation  of  the  exposed  pulp.  Sometimes, 
however,  it  is  necessary  to  use  a  small  amount  of  sterile 
water;  but  one  should  apply  only  enough  to  reduce  the 
pellet  to  a  paste.  A  piece  of  unvulcanized  rubber,  slightly 
warm,  is  placed  into  the  cavity.  It  should  be  just  large 
enough  to  fill  three-quarters  of  the  cavity.  A  flat-ended 
instrument  the  size  of  the  cavity  is  used  to  press  the  rubber 
in  the  direction  of  the  pulp  canal;  this  will  prevent  the 
solution  escaping  at  the  sides.  Pressure  should  be  applied 
slowly,  with  an  evenly  increasing  force,  so  as  to  minimize  the 


SPECIAL    TECHNIQUE  OF  LOCAL  ANESTHESIA  93 

pain.  When  all  pain  has  disappeared  remove  the  rubber, 
and  with  a  sterile  bur  open  the  pulp  chamber  and  remove 
the  pulp. 

INFILTRATION  ANESTHESIA 

In  this  method  the  anesthetic  solution  is  injected  be- 
neath the  mucous  membrane  or  the  skin,  as  the  case  may  be. 
Anesthesia  is  induced  by  the  action  of  the  anesthetic  on  the 
terminal  nerve  fibers.  The  method,  therefore,  is  also  called 
terminal  or  peripheral  anesthesia.  Its  action  is  limited  to 
a  small  area,  and  a  considerable  amount  must  be  injected 
when  a  large  field  is  to  be  anesthetized.  In  certain  parts 
of  the  jaws,  the  solution  will  penetrate  the  bone,  traveling 
through  the  Haversian  canals.  In  localities  where  these 
canals  are  numerous  and  where  the  apices  of  the  teeth  are 
near  the  surface,  we  are  able  to  make  use  of  infiltration  to 
anesthetize  the  teeth,  the  solution  affecting  the  dental  nerves 
before  they  enter  the  apical  foramen. 

The  infiltration  method  gives  quick  results;  but  it  can- 
not be  employed  for  deep  action,  especially  with  regard  to 
its  effect  on  the  teeth.  The  injection  is  more  painful  than 
for  the  conductive  method,  particularly  if  the  mucous  mem- 
brane is  in  an  inflamed  condition;  furthermore  it  must  be 
repeated  a  number  of  times  to  cover  a  large  field.  If  sup- 
puration is  present,  the  method  is  entirely  contraindicated 
on  account  of  the  danger  of  spreading  infection. 

Anatomical  Considerations.  The  face  is  covered  by  the 
common  integument,  which  is  similar  in  structure  to  the  skin 
covering  other  parts  of  the  body.  It  consists  of  the  epidermis 
and  the  corium.  The  latter  is  a  layer  of  densely  interwoven 
bundles  of  connective  tissue,  forming  papillae  immediately 
under  the  epidermis.  These,  however,  in  the  face  are  not 
well  developed.  In  each  papilla  there  is  a  terminal  knot 
of  capillar>^  blood  vessels  and  nerve  endings.  Through  the 
corium  extend  the  hair  shafts  and  ducts  which  are  the  out- 


94  ORAL  ANESTHESIA 

lets  of  the  sweat  glands  found  in  the  stratum  subcutaneum. 
Here  also  we  find  fat  glands  and  numerous  vessels. 

At  the  transitional  part  of  the  lips  the  mucous  mem- 
brane of  the  mouth  begins.  The  oral  cavity  is  lined  by 
stratified,  squamous  epithelium,  papillae  of  which  extend  into 
the  tunica  propria.  Underneath  this  is  the  submucosa 
which  connects  the  mucous  membrane  with  the  underlying 


Figure  37 
Microscopic  drawing  of  a  section  through  skin  overlying  bone, 
a.  Epidermis;  b.  corium;  c.  subcutaneous  tissue;  d.  perios- 
teum; e.  bone.  Endermic  injection  is  made  into  b  directly  be- 
neath epidermis.  Subcutaneous  injection  is  made  into  c.  Sub- 
periosteal injection  between  d  and  e. 

structures.  In  certain  locations,  it  contains  numerous  mu- 
cous glands  varying  in  size,  the  ducts  of  which  wind  through 
the  tunica  propria  until  they  find  an  outlet  at  the  surface 
of  the  epithelium.  The  gums  have  a  very  dense  sub- 
mucosa, consisting  of  thick  connective  tissue  bundles, 
containing  numerous  elastic  fibers  which  extend  into  the 
periosteum,   binding   the   mucous   membrane   closely   down 


SPECIAL   TECHXIQUE  OF   LOCAL  ANESTHESIA  95 

to  the  bone.  At  the  reflection  of  the  mucous  membrane, 
where  it  turns  over  cheek,  Hps,  or  the  floor  of  the  mouth, 
the  submucosa  becomes  loose  and  is  represented  by  a  thick 
layer  of  connective  tissue.  A  similar  condition  is  found  on 
the  palatal  side,  where  the  angle  formed  by  the  alveolar  and 
palatal  processes  is  padded  with  a  large  amount  of  con- 
nective tissue.  This  connective  tissue  contains  a  great 
deal  of  fat  and  most  of  the  mucous  glands  of  the  hard  palate. 
Towards  the  center  of  the  roof  of  the  mouth  the  mucous 
membrane  is  very  thin,  extremely  fibrous,  and  closely  attached 
to  the  bone.  The  blood  supply  of  the  mucous  membrane  is 
ver\'  free.  Larger  branches  are  found  in  the  submucosa 
giving  off  capillaries,  which  extend  into  the  papiUae  of  the 
tunica  propria.     Here  they  ramify  mdely  and  anastomose. 

The  nerve  endings  seem  to  be  more  numerous  in  the  an- 
terior part  of  the  mouth,  where  the  mucous  membrane  is 
much  more  sensitive  than  in  the  back.  Primitive  nerve 
fibers  extend  from  the  submucosa  into  the  papillae  of  the 
tunica  propria,  where  they  terminate. 

Technique  of  Injection.  General  Remarks.  When  the 
syringe  has  been  filled  it  should  be  held  in  readiness  either  by 
the  nurse  or  assistant,  or  placed  within  reach  of  the  oper- 
ator, but  in  such  a  manner  as  to  prevent  it  from  coming 
into  contact  with  anything  but  sterile  conditions.  This 
especially  applies  to  the  needle.  Some  operators  place  a 
piece  of  sterile  cotton  or  gauze  saturated  with  absolute  or 
70  per  cent  alcohol  over  the  needle.  If  the  needle  is  to  be 
adjusted  after  sterilization,  use  sterfle  instruments  for  the 
purpose.  The  needle  should  not  be  touched  with  the  fingers 
under  any  circumstances.  In  case  of  doubt,  it  should  be 
resterilized.  At  this  time  make  sure  that  no  air  is  in  the 
syringe,  because  air  injected  into  the  tissue  causes  pain. 
Retract  the  Yip  or  cheek  and  prepare  the  mucous  membrane  as 
previously  described.  When  inserting  the  needle,  carry  it 
down  at  once  into  the  submucous  tissue,  but  not  into  the 


96  ORAL  ANESTHESIA 

bone,  or  the  point  of  the  needle  will  be  bent.  It  should  be 
borne  in  mind  that  a  sharp  needle  causes  less  pain  than  a 
blunt  one  and  a  blunt  point  tears  the  delicate  tissue  fibers. 
When  injecting  into  the  mucous  membrane,  the  dense  part 
near  the  alveolar  margin  should  be  avoided.  The  old 
method  of  anesthetizing  the  gum  required  enormous  force 
and,  therefore,  caused  a  great  deal  of  pain.  The  loose  part  of 
the  submucosa  should  be  reached  as  soon  as  possible,  for  here 
the  solution  is  taken  up  easily  and  with  little  pressure.  Con- 
tinuous and  slow  advancement  of  the  needle  will  obviate 
the  danger  of  injecting  into  an  artery  or  vein.  The  force 
of  the  solution  flowing  from  the  point  of  the  needle  has  a 
tendency  to  push  aside  small  vessels. 

Infiltration  of  the  Skin  and  Mucous  Membrane 

The  nerve  supply  of  the  skin  and  mucous  membranes  is 
extremely  complicated.  Nerve  branches  originating  from 
various  sources  anastomose  and  form  an  intricate  mesh- 
work.  It  is  therefore  necessary,  if  operations  include  the 
soft  parts  of  the  face,  to  supplement  conduction  anesthesia 
with  regional  infiltration.  This  also  affords  an  opportunity  to 
produce  local  anemia  for  a  bloodless  field  of  operation  if  desired. 

Infiltration  of  both  the  skin  and  mucous  membrane 
may  be  accomplished  either  by  endermic  or  subcutaneous 
injections.  In  the  endermic  method,  the  end  organs  of 
the  nerves  are  anesthetized  directly  in  the  skin.  The  solu- 
tion should  be  injected  as  near  the  surface  as  possible,  that 
is,  directly  under  the  epidermis  or  the  epithelium,  to 
bring  it  in  direct  contact  with  the  nerve  ending  in  the 
papillae  of  the  corium  or  tunica  propria.  In  subcutaneous 
injections,  the  solution  is  injected  into  the  subcutaneous 
tissue  or  the  submucosa.  Here  the  solution  affects  the 
nerve  filaments,  and  as  it  has  to  penetrate  the  nerve 
sheaths,  it  requires  more  time  for  the  anesthesia  to  take 
effect  and  a  greater  amount  of  solution  is  required. 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  97 


Figure  38 
Section  through  the  upper  jaw  in  the  incisor  region.  A. 
Enamel;  B.  Dentin;  C.  Interglobular  spaces;  D.  Epithelium; 
E.  Tunica  propra;  F.  Submucosa;  G,  Periosteum;  H.  Outer 
Plate  of  alveolar  process;  I.  Inner  Plate  of  alveolar  process; 
K.  Cement;  L.  Dental  nerves  and  vessels. 


98  ORAL  ANESTHESIA 

Instruments.  Use  a  syringe  with  a  short  fine  needle  for 
endermic  injections.  For  subcutaneous  injections,  use  a 
long  needle.  The  larger  the  needle,  the  better  it  allows 
progress  in  advancement,  and  a  larger  field  can  be  covered 
with  one  puncture.     (Use  long  needle  shown  in  Figure  26.) 

Technique  of  Injection.  Endermic  Method.  The  skin 
is  picked  up  with  thumb  and  forefinger,  and  while  applying 
considerable  pressure  to  render  it  less  sensitive,  the  needle 
is  inserted.  Inject  at  once.  The  blood  is  pressed  out  of 
the  capillaries,  causing  blanching  of  the  skin  or  mem- 
brane. Inject  slowly  with  even  pressure,  so  as  not  to  cause 
any  pain  by  rapidly  expanding  the  tissue.  The  needle  should 
remain  close  to  the  surface.  It  is  inserted  again  at  the 
distal  periphery  of  the  blanched  area  and  this  is  repeated 
until  the  entire  area  is  anesthetized.  The  more  solution  is 
injected  at  each  puncture,  the  wider  becomes  the  anesthetized 
area.  Anesthesia  takes  effect  almost  immediately,  but  as 
the  blanched  appearance  disappears  rapidly,  it  is  best  to 
first  mark  the  place  to  be  incised. 

Subcutaneous  Method.  The  skin  is  picked  up  as  pre- 
viously described,  but  the  needle  passes  at  once  into  the 
subcutaneous  or  submucous  tissue.  This  tissue  is  generally 
very  loose;  therefore  little  pressure  is  required,  and  the  solu- 
tion is  taken  up  freely.  The  needle  is  slowly  advanced 
while  injecting  until  it  is  inserted  to  its  full  extent.  It  can 
then  be  partly  withdrawn  and  advanced  in  another  direction 
or  else  withdrawn  entirely  and  reinserted  at  a  different  place. 
A  larger  area,  however,  can  be  covered  by  one  puncture  if 
the  needle  is  long  enough.  Anesthesia  occurs  in  about 
five  minutes. 

Infiltration  Method  for  Anesthetizing  Individual  Teeth 

For  any  purely  dental  operation,  such  as  is  necessary  for 
restoration  or  the  removal  of  the  pulp,  anesthesia  of  the 
dentinal  nerve  fibers  supplying  the  tooth  and  peridental 
membrane   can   be   accomplished   in    certain   parts   of   the 


Figure  39  t     .     . 

Sections  ihrough  Iceth  in  situ,  to  show  the  rclalion  of  the  tooth  root  to  the 
surface  of  the  bone.  i.  Central  incisor;  2.  lateral  incisor;  s-  cuspid;  4.  first 
bicuspid;  5.  second  bicuspid;  6.  llrst  molar;  7.  second  molar;  8.  third  molar 
of  upper  jaw.     A.    incisor;    H.    bicuspid;   ('.    molar  of  lower  jaw. 

Shaded  area  shows  where  injection  should  be  made.  The  sections  which 
show  no  area  cannot  be  anesthetized  by  this  method. 


lOO  ORAL  ANESTHESIA 

mouth  by  the  infiltration  method.  The  solution  is  injected 
as  close  to  the  bone  as  possible,  from  where  it  penetrates 
through  the  Haversian  canals.  It  is  not  necessary,  to  make 
a  special  effort  to  insert  the  needle  beneath  the  periosteum. 
In  the  writer's  opinion,  subperiosteal  injections  are  liable 
to  cause  swelling  and  pain,  because  they  tend  to  detach 
the  periosteum  from  the  bone.  In  children  and  adults  with 
thin  bone,  infiltration  is  usually  more  successful  than  in  old 
persons  and  patients  with  heavy  bone,  because  in  the  former 
there  is  as  a  rule  an  abundance  of  pores,  through  which  the 
solution  can  pass.  In  the  upper  jaw,  the  incisors  and 
bicuspids  are  the  most  easily  anesthetized.  Next  come  the  cus- 
pids and  third  molars,  while  difficulties  are  sometimes  en- 
countered with  the  first  and  second  molars,  on  account  of 
the  zygomatic  process,  which  in  a  number  of  cases  is  very 
near  the  alveolar  margin,  increasing  the  thickness  of  the 
bone  at  the  buccal  side. 

The  lower  jaw  affords  opportunity  for  infiltration  only 
in  the  anterior  part  and  is  usually  unsatisfactory  for  the 
cuspids,  bicuspids,  and  molars. 

Technique  of  Injection.  As  a  general  rule,  use  the  fol- 
lowing injections,  if  only  the  tooth  is  to  be  anesthetized: 

Labial  or  buccal  injection  alone  on  single-rooted  teeth. 

Buccal  and  lingual  injection  both  on  multi-rooted  teeth. 

If  both  the  tooth  and  surrounding  tissue  are  to  be  anes- 
thetized, as  for  extraction  or  other  surgical  procedure,  use: 

Labial  or  buccal  and  lingual  injections  on  all  teeth. 

Instruments.  The  syringe  with  the  short  iridio-platinum 
needle  (26  mm.)  and  mounted  with  the  short  hub  is  gen- 
erally used  for  infiltration  anesthesia.  If  the  operator  has 
become  proficient  in  handling  the  syringe,  and  especially  if  he 
uses  conduction  anesthesia  in  most  cases,  the  long  needle 
mounted  with  the  long  hub  can  be  used  for  both  methods. 
This  simplifies  the  equipment.  The  long  needle,  however, 
bends  easily  and  special  care  is  required  so  as  not  to  spoil  it. 


SPECIAL   TECHNIQUE  OF   LOCAL   ANESTHESIA 


lOI 


Technique.  The  needle  is  inserted  into  the  sterihzed 
place  with  the  opening  of  the  needle  facing  the  bone. 
In  the  beginning,  it  is  advisable  to  hold  the  syringe  like  a 
writing   pen.     This   method   givxs    the    operator   a    chance 


Figure  40 
Wrong  position  of  needle. 


Figure  41 
Right  position  of  needle. 


Position  of  operator 
infiltration  method. 


Figure  42 
when  injecting  for  an  upper  tooth  by  the 


to  steady  his  hand  against  the  patient's  jaw.  Later,  how- 
ever, it  may  be  taken  hold  of  in  a  manner  which  allows  the 
injection  of  a  few  drops,  immediately  after  the  puncture  is 
made.     If  this  method  is  adopted,  it  is  often  possible  to  make 


I02  ORAL  ANESTHESIA 

use  of  the  left  hand,  which  is  used  for  retracting  the  hp  or 
cheek,  as  a  support  for  the  syringe  hand.  The  needle  then 
is  carefully  and  slowly  advanced,  injecting  continuously  a 
small  amount  until  a  place  opposite  or  a  little  higher  than 
the  apex  of  the  tooth  is  reached.  Here  the  remainder  of 
the  solution  is  deposited.  The  injection  should  be  made 
evenly.  At  no  time  should  it  require  an  unusual  amount  of 
force.  No  velum  should  be  produced,  as  in  the  old  way 
of  injecting  into  the  gum.  The  formation  of  a  velum  is  a  sign 
that  the  needle  has  not  been  inserted  in  the  deepest  part  of 
the  tissue.  Sometimes  a  great  deal  of  resistance  is  experi- 
enced, which  may  be  followed  by  sudden  release.  This 
causes  the  operator  to  inject  a  large  amount  all  at  once, 
and  produces  injury  which  is  usually  followed  by  after  pain 
and  soreness.  When  the  injection  is  made  carefully,  slowly, 
and  with  an  even  flow  of  the  solution,  less  pain  is  experi- 
enced by  the  patient.  After  removing  the  syringe,  which 
should  be  done  swiftly,  it  is  necessary  to  wait  for  the  solu- 
tion to  infiltrate  the  bone.  It  takes  from  five  to  eight  minutes 
for  the  tooth  to  become  anesthetized.  When  the  solution  is 
seen  to  come  out  through  the  opening  made  by  the  needle, 
a  strong  astringent  such  as  tannic  acid  in  glycerin  should 
be  applied  at  once  on  sterile  cotton  or  gauze.  Pressure 
applied  to  the  part  sometimes  also  prevents  the  flowing  out 
of  the  solution.  Some  operators  advise  the  massaging  of 
the  part  injected  so  as  to  force  the  solution  into  the  bone, 
but  according  to  the  writer's  experience  this  is  only  necessary 
in  isolated  cases. 

Injection  on  the  Labial  or  Buccal  Side  in  the  Upper  Jaw. 
The  place  where  the  needle  should  be  inserted  on  the  labial 
or  the  buccal  surface  of  the  jaw  is  directly  over  the  eminence 
of  the  root,  halfway  between  the  gum  margin  and  the  apex. 
In  the  molar  region,  it  is  often  necessary  to  deviate  from 
this  rule,  pushing  the  needle  obliquely  to  the  intended  place, 
where  the  main  part  of  the  solution  is  deposited. 


SPECIAL    TECHNIQUE  OF   LOCAL  ANESTHESIA  103 

Injection  on  the  Lingual  Side  of  the  Upper  Jaw.     The 

Ungual  gum  of  the  maxilla  is  supplied  by  the  anterior  pala- 
tine and  naso-palatine  nerves;  therefore  for  surgical  opera- 
tions an  additional  injection  to  produce  anesthesia  of  the 
soft  parts  is  rec|uired.  For  the  molars,  and  often  for  the 
first  bicuspid,  the  lingual  injection  is  needed  for  complete 
anesthesia  of  the  tooth,  as  it  anesthetizes  the  palatal  root. 


Figure  43 
Roentgen  picture,  showing  the  position  of  needle  to  anesthetize 
an  upper  incisor  by  the  infiltration  method. 

On  the  lingual  side  we  start  at  the  gingival  margin,  push 
the  needle  at  once  down  parallel  with  the  process  into  the 
submucous  tissue,  which  takes  up  the  solution  easily,  recjuir- 
ing  little  force. 

Injection  on  the  Labial  Side  of  the  Mandible.  Here  the 
procedure  is  similar  to  that  used  for  the  maxilla.  Often, 
however,  it  is  easier  to  insert  the  needle  over  the  tooth  next 


I04 


ORAL  ANESTHESIA 


to  the  one  that  is  to  be  anesthetized,  pushing  it  obHquely 
toward  the  apex  of  the  tooth  in  question. 

Injection  at  the  Lingual  Side  of  the  Mandible.  The 
mouth  should  be  open  as  wide  as  possible.  The  procedure 
is  the  same  as  described  for  the  maxilla.  The  lingual  gum 
is  supplied  by  the  lingual  nerve.  This  injection  is  only 
necessary  in  case  of  extraction  of  the  lower  incisors. 


Figure  44 
Roentgen  picture,  showing  position  of  needle  to  anesthetize  an 
upper  cuspid. 

For  Upper  Central  Incisors.  The  apex  of  this  tooth  lies 
close  to  the  outer  surface  and  its  root  is  about  the  same 
length  as  the  crown  or  a  little  longer.  When  the  needle  is 
inserted  on  the  labial  side  to  the  full  extent,  it  often  meets  with 
resistance,  due  to  a  prominence,  the  nasal  spine.  (See 
Figure   43.)     Do   not,   therefore,  force   the   needle   further, 


lO: 


SPECIAL    TECHNIQUE   OF   LOCAL   ANESTHESIA 

or  it  will  bend.     For  extraction,  an  additional  injection  on 
the  palatal  side  is  necessary. 

For  Upper  Lateral  Incisors.  The  root  of  the  lateral  is 
usually  longer  than  the  central  root  and  often  is  bent  distally. 
It  is  placed  in  the  center  of  the  bone  and  its  apex  is  there- 
fore generally  further  from  the  surface  than  the  apex  of  the 


Figure  45 
Roentgen  picture,  showing  position  of  needle  to  anesthetize  an 
upper  bicuspid. 

central.     The  injections  are  made  in  the  same  manner  as 
for  the  previously  described  tooth. 

For  Upper  Cuspids.  This  tooth  has  a  very  long  root;  in 
extreme  cases,  almost  twice  as  long  as  the  crown.  The  needle 
therefore  should  be  inserted  higher  up,  unless  a  42  mm. 
needle  is  used,  which  is  long  enough  to  reach  the  proper 
region,     (ienerally,  the  root  is  covered  only  by  a  thin  layer 


io6  ORAL  ANESTHESIA 

of  bone,  and  it  can  be  easily  anesthetized,  if  the  injection  is 
made  by  following  the  canine  eminence  to  a  point  a  little 
higher  than  the  apex  of  the  tooth.  An  injection  should 
be  made  also  on  the  lingual  side  if  surgical  work  is  intended. 

For  Upper  First  Bicuspids.  This  tooth  nearly  always 
has  two  roots,  which  are  about  one  and  one  half  times  as  long 
as  the  crown.  Both  their  apices  are  near  the  surface.  In- 
jections should  be  made  on  the  buccal  and  lingual  sides  in 
order  to  reach  both  the  dental  nerves,  one  entering  the  buc- 
cal and  one  entering  the  palatal  root.  It  is  best  to  use  this 
procedure  every  time,  disregarding  the  possibility  of  an 
occasional  single  root. 

For  Upper  Second  Bicuspids.  For  this  tooth,  one  in- 
jection on  the  buccal  side  is  nearly  always  sufficient  for 
purely  dental  operations.  The  lingual  gum  has  to  be  taken 
care  of  with  an  additional  injection,  if  the  soft  tissues  are 
to  be  included  in  the  operation. 

For  Upper  First  Molars.  The  nerves  leading  to  the 
pulp  of  this  tooth  in  most  cases  cannot  be  reached  by 
the  infiltration  method.  In  children,  conditions  are  more 
favorable.  Sometimes,  however,  we  find  anatomical  con- 
ditions which  make  infiltration  possible,  such  as  when  the 
zygomatic  process  emerges  higher  than  usual  or  when  the 
alveolar  process  is  especially  long.  It  is  necessary  to  insert 
the  needle  obliquely,  backward  and  upward,  because  the 
opening  of  the  mouth  does  not  allow  a  vertical  direction. 
A  place  between  and  a  little  higher  than  the  apices  of  the 
buccal  roots  should  be  reached,  and  a  separate  injection  is 
necessary  on  the  lingual  side  for  the  nerve  entering  the 
palatal  root. 

For  Upper  Second  Molars.  The  conditions  of  the  bone 
around  this  .tooth  are  mostly  unfavorable,  depending  more  or 
less  on  the  formation  of  the  zygomatic  process  of  the  max- 
illa. All  that  has  been  said  about  infiltration  anesthesia 
for  the  upper  first  molar  may  be  applied  to  this  tooth. 


SPECIAL    TECHNIQUE  OF  LOCAL  ANESTHESIA  107 

For  Upper  Third  Molars.  The  third  molar  is  easy  to 
anesthetize,  the  bone  being  very  porous.  As  its  roots  are 
generally  not  divergent  and  mostly  fused,  a  buccal  injection 


Figure  46 
Roentgen  picture,  showing  position  of  needle  to  anesthetize  a 
lower  incisor. 

is  usually  sufficient.  The  patient  should  be  directed  to 
open  the  mouth  but  slightly  and  completely  relax  the  muscle 
of  the  cheek.  This  makes  it  possible  to  sufficiently  retract 
the  corner  of  the  mouth,  and  gives  access  for  insertion  of  the 


io8 


ORAL  ANESTHESIA 


Figure  47 
Roentgen  picture,  showing  position  of  the  needle  for  a  horizontal  injection. 


Figure 

Roentgen  picture,  showing  position  of  needle  for  a  horizontal  injection, 
the  cuspid,  both  bicuspids,  and  first  molar   having  been  anesthetized. 


SPECIAL    TECHNIQUE  OF  LOCAL   ANESTHESIA  109 

needle.  A  long  needle  is  desirable  and  should  be  directed 
over  the  middle  of  the  root  of  the  second  molar.  It  is  then 
pushed  inward  and  slightly  upward,  until  the  point  reaches 
a  slightly  higher  level  than  the  apex  of  the  wisdom  tooth. 
For  surgical  operations,  use  also  a  palatal  injection. 

For  the  Lower  Incisors.  The  lower  incisors  are  easily 
anesthetized  by  means  of  the  infiltration  method,  as  the 
bone  is  very  porous,  especially  on  the  anterior  surface 
opposite  their  roots.  To  make  the  injection  more  con- 
veniently, the  needle  is  inserted  obliquely,  starting  over  the 
tooth  nearer  the  operator,  but  care  should  be  taken  that 
the  point  of  the  needle  reaches  a  spot  opposite  the  apex 
of  the  tooth  to  be  anesthetized.  An  injection  on  the  lingual 
side  is  necessary  for  surgical  anesthesia,  but  is  not  always 
easily  accomplished,  especially  if  the  incisors  have  a  lingual 
inclination.  The  patient  should  be  instructed  to  open  the 
mouth  as  wide  as  possible.  For  extracting,  it  is  only 
necessary  to  inject  into  the  gum  margin.  Often  it  is  found 
of  great  help  to  use  the  long  needle,  which  has  been  bent 
before  being  sterilized. 

Infiltration    Method   for   Anesthetizing   a   Number   of 
Adjoining  Teeth 

To  avoid  repeated  puncture  of  the  mucous  membrane, 
when  several  adjoining  teeth  are  to  be  anesthetized  by  the 
infiltration  method,  the  long  needle  should  be  inserted  over 
the  apex  of  the  root  of  the  tooth  farthest  forward  or  nearest 
the  operator.  Having  injected  for  the  first  tooth,  the  needle 
should  be  forced  along  the  bone  in  a  horizontal  direction,  un- 
til the  place  opposite  the  apex  of  the  second  tooth  has  been 
reached;  here  again  deposit  some  of  the  solution  and  pro- 
ceed in  the  same  manner  for  the  next  tooth.  This  method 
can  be  used  for  a  series  of  teeth  in  the  incisor  region,  in  the 
upper  as  well  as  in  the  lower  jaw,  and  for  anesthetizing 
adjoining    maxillary    bicusi)ids    and    molars.     The    use    of 


no  ORAL  ANESTHESIA 

the  horizontal  injection  is  only  advisable  in  healthy  tissue, 
on  account  of  the  danger  of  spreading  infection.  For  sur- 
gical anesthesia,  the  lingual  side  must  also  be  anesthetized. 
The  tables  on  pages  140  and  141  give  the  amounts  to  be  in- 
jected for  each  tooth. 

CONDUCTION   ANESTHESIA 

Conduction  anesthesia  is  the  ideal  method  of  producing 
local  anesthesia.  Its  action  is  to  intercept  or  block  the 
conductivity  of  a  nerve  at  a  convenient  point,  in  order  to 


I 

V 

I 
1^ 

In,    ... 

_--B 

A- 

■V- 

%      - 

^,.^-' 

■4' 

>„•    ■ 

^.: 

% 

y" 

-'*-^',«i^     . 

I 

T 
I 

I 

FiGUEE   49 

Cross  section  through  a  nerve  trunk.  The  whole  trunk  is  sur- 
rounded by  a  dense  layer  of  tissue  called  the  epineurium,  (A) 
Each  nerve  bundle  is  surrounded  by  a  similar  layer  called  peri- 
neurium, (B)  The  needle  (N)  illustrates  an  intraneural  injection. 
The  arrows  (I)  indicate  infiltration  of  the  nerve  in  extraneural  in- 
jections. 

prevent  afferent  impulses  from  reaching  the  brain.  The 
injection  is  made  into  loose  connective  tissue  or  a  bony  canal, 
at  some  distance  from  the  field  of  operation,  which  lessens 
the  possibility  of  infection  and  the  tendency  to  post- 
operative pain. 


SPECIAL    TECHNIQUE  OF   LOCAL   ANESTHESIA  iii 

Infiltration  anesthesia  may  be  combined  with  conduction 
anesthesia,  especially  if  it  is  desirable  to  have  a  bloodless 
field  of  operation.  The  main  advantages  over  the  infiltra- 
tion method  are  the  following: 

1.  A  comparatively  large  area  can  be  covered  by  the 
injection,  anesthetizing  equally  well  the  superficial  tissue, 
the  deeper  parts,  soft  tissue  as  well  as  bone,  and  in  the  jaws 
all  the  teeth  supplied  by  the  injected  nerve. 

2.  The  needle  is  inserted  at  a  place  generally  quite 
distant  from  the  field  of  operation.  The  injection  may  be 
made  into  the  nerve  trunk  itself  (endoneural  injection)  or 
in  the  tissue  surrounding  the  nerve  (perineural  injection). 
In  the  first  method,  it  is  necessary  to  expose  the  nerve,  which 
is  usually  done  with  infiltration  anesthesia.  It  is  more 
frequently  practiced  in  connection  with  general  anesthesia. 
The  perineural  injections  are  almost  entirely  used  in  den- 
tistry and  oral  surgery.  The  solution  is  injected  into  the 
neighborhood  of  the  nerve  into  which  it  diffuses.  The  time 
necessary  for  the  solution  to  affect  the  nerve  is  dependent 
upon  the  thickness  of  the  nerve  trunk  and  the  density  of 
the  perineurium.  The  part  supplied  by  the  nerve  fibers 
located  in  the  periphery  is  anesthetized  first,  the  part  sup- 
plied by  the  centrally  located  fibers  last  and  sometimes 
not  as  efficiently. 

3.  The  point  of  injection  is  generally  remote  from  parts 
which  are  diseased  and  hypersensitive.  This  not  only  de- 
creases the  pain  made  by  the  puncture  but  is  a  safeguard 
against  spreading  of  the  disease  into  deeper  or  neighboring 
tissue.     It  also  minimizes  postoperative  pain. 

4.  The  anesthesia  is  as  a  rule  of  longer  duration  and 
the  time  can  be  controlled  by  the  amount  injected.  If 
necessary,  the  injection  can  be  repeated  at  any  stage  of 
the  operation. 

Accurate  knowledge  of  anatomy  and  skill  in  technifjue 
is  required  for  the  successful  use  of  conduction  anesthesia. 


112 


ORAL  ANESTHESIA 


H      FE        y       ZA     B  CD 


Figure  50 

Horizontal  section  through  the  human  head  in  the  plane  in 
which  mandibular  conduction  anesthesia  is  best  accomplished, 
a.  Glandula  parotis;  b.  Ramus  mandibulae;  c.  Fascia  paro- 
tideomasseterica;  d.  A.  and  V.  alveolaris  inf.;  e.  Nervus  alveo- 
laris  inf.;  f.  Spatium  pterygomandibulare ;  g.  M.  masseter; 
h.  M.  pterygoid  int.;  i.  Nervus  Hngualis;  k.  M.  buccinator; 
1.  Glandulae  palatinae;  m.  Art.  maxiUaris  externa;  n.  Glan- 
dulae  buccaUs;  o.  Gingiva;  p.  Labium  inferius;  q.  Lingua; 
r.  Glandulae  buccalis;  s.  M.  masseter;  t.  M.  Diagastricus;  u. 
Art.  carotis  externa;  v.  Vena  jugularis  interna;  w.  N.  vagus, 
glossopharyngeus  and  hypoglossus;  x.  Art.  carotis  interna;  y. 
Ganglion  cervicale  superior;  z.   M.  longus  capitis. 

A.  M.  rectus  capitis  anterior;  B.  Epistropheus;  C.  M.  con- 
strictor pharyngis  superior;  D.  Fascia  praevertebralis;  E.  M. 
stylopharyngeus;  F.  M.  styloglossus;  G.  Tonsilla  palatine; 
H.  M.  Stylohyoideus. 


SPECIAL    TECHNIQUE  OF  LOCAL  ANESTHESIA  113 

INTRAORAL   METHODS   OF   CONDUCTION   ANESTHESIA 

In  the  intraoral  methods,  the  nerve  to  be  anesthetized 
is  approached  from  within  the  oral  cavity.  Intraoral  in- 
jections will  probably  always  be  more  popular  than  the 
extraoral  ones,  although  the  latter  have  distinct  advantages 
which  will  be  discussed  later: 

The  Pterygomandibular  Injection 

For  the  Lingual  and  Inferior  Alveolar   Xervc 
With  this  method  the  inferior  alveolar  nerve  is  reached 
before  it  enters  the  mandibular  foramen,  resulting  in  anes- 
thesia of  half  of  the  mandible,  half  of  the  lower  lip,  and  the 


Figure  51 
Diagram  showing  injection  into  the  pterygomandibular  space. 
a.  N.  Alveolaris  inf.;  b.  A.  Alveolaris  inf.;  c.  X.  Lingualis; 
d.  Spatium  pterygomandibulare;  e.  Linea  obi.  externa;  f.  Linea 
obi.  interna;  g.  Trigonium  retromolare;  h.  Ramus  mandibulae; 
i.   M.  Masseter;   f.  M.  Pterygoid  int.;   I.    Position  of  needle. 

teeth.  The  lingual  nerve,  which  not  only  supplies  the  tip 
of  the  tongue  but  also  the  lingual  part  of  the  gum,  is  sit- 
uated very  near  the  place  where  the  needle  is  inserted  and 
can  also  easily  be  included. 

Anatomical  Considerations.     It  is  important  to  have  a 
mental    picture    of    the    associated   anatomical   structures. 


114  ORAL  ANESTHESIA 

Frozen  sections  cut  in  coronal  and  frontal  plane  about  one^ 
half  inch  apart  furnish  an  excellent  means  of  instruction. 
Figure  50  shows  a  drawing  made  from  a  coronal  section  cut 
exactly  through  the  plane  in  which  the  needle  is  inserted. 
Note  the  internal  oblique  line  of  the  ramus,  from  which  a 
fascia  extends  around  the  internal  pterygoid  muscle,  at  the 
anterior  margin  of  which  lies  the  lingual  nerve.  Between 
the  muscle  and  the  inner  surface  of  the  ramus  is  a  space,  the 
circumference  of  which  marks  the  sulcus  mandibularis,  seen 


Figure  52 
The  needle  should  be  inserted  into  the  sulcus  mandibularis  over 
the  lingula. 

in  Fig.  15.  This  space  is  called  the  pterygomandibular 
space.  It  is  filled  with  connective  tissue  and  contains  the 
inferior  alveolar  nerve  and  artery.  Here  they  enter  the 
bone.  The  nerve  in  this  location  generally  lies  anterior  to 
the  artery,  which  is  of  moderate  size.  The  artery  is  a 
branch  of  the  internal  maxillary  artery  and  passes  down 
between  the  spheno-mandibular  ligament  and  the  mandible. 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA 


115 


The  inferior  alveolar  vein  forms  a  plexus  around  the  artery. 
The  lingula  more  or  less  projects  over  and  partly  surrounds 


FiGUKE    53 

Roentgen  picture  showing  needle  inserted  over  the  lingula 
into  the  pterygomandibular  space. 

these  structures.  If  the  needle  is  inserted  too  low,  it  may  be 
easily  guided  into  the  muscle.  Therefore  care  should  be 
taken  to  inject  at  a  higher  level. 


Ii6  ORAL  ANESTHESIA 

Instruments.  Use  syringe  No.  i,  mounted  with  the  long 
45  mm.  iridio-platinum  needle,  and  the  long  straight  hub. 

Landmarks.  The  post-molar  triangle  is  located  by  pal- 
pating first  the  external  oblique  line  of  the  ramus,  which  is 
very  prominent,  then  the  internal  oblique  line  which  varies 
greatly  in  prominence  and  form.  The  tip  of  the  finger 
rests  easily  in  the  depression  between  the  two.  This  manip- 
ulation should  be  done  gently  and  later  can  be  omitted 
entirely. 

Technique.  Various  methods  have  been  described  for 
this  injection.  They  differ,  however,  only  in  minor  points. 
Seidel  employs  the  thumb  of  the  left  hand  for  palpation  on 
either  side.  Fischer  and  Smith  recommend  the  use  of  the 
index  finger  of  the  left  hand  while  Blum  teaches  the  use  of 
the  index  finger  of  the  left  hand  for  the  left  side.  For  the 
right  side  he  uses  the  right  index  finger  for  palpation  and 
the  left  hand  to  hold  the  syringe  and  make  the  injection. 
The  method  described  hereafter  has  been  found  easiest  to 
learn  and  most  convenient  by  the  writer. 

For  the  right  side  of  the  mandible  stand  on  the  right 
side  of  the  chair  facing  the  patient.  Find  the  post-molar 
triangle  with  the  tip  of  the  thumb  of  the  left  hand,  applying 
the  other  fingers  to  the  outside  of  the  jaw.  This  position 
enables  the  operator  to  steady  the  head.  The  finger  nail 
marks  the  location  of  the  internal  oblique  line  and  the 
needle  is  inserted  close  to  the  nail;  but  the  operator  should 
prevent  any  contact  which  would  destroy  the  asepsis  (Fig. 

54,i). 

For  the  left  side  stand  further  back  facing  in  the  same 
direction  as  the  patient.  The  left  arm  should  extend  around 
the  patient's  head,  the  regular  position  for  the  use  of  the 
mouth  mirror  on  that  side.  Palpate  the  post  molar  tri- 
angle with  the  tip  of  the  left  index  finger,  the  finger  nail 
facing  the  median  line.  The  other  fingers  again  take  hold 
of  the  outside  of  the  jaws  as  seen  in  Fig.  54,  4. 


I'li.i  Ki;  54 
Technique  of  inserting  the  needle  for  the  pterygomandibular  injection,    i,  2, 
and  3,  on   the   righl  side;   4,  5,  and  6,  on  the   left   side,     i  and  4,  feeling  of 
the  internal  ohiifjue  line.     2  and  5,  adjusting  position  of  the  syringe  parallel 
with  the  ramus.     3  and  5,  reaching  the  plerygomandil)uiar  si)ace. 


Hi 


ORAL  ANESTHESIA 


After  finding  the  proper  position,  prepare  the  mucous 
membrane  for  the  puncture  in  the  usual  manner.  The 
position  of  the  left  hand  is  not  changed  until  the  injection 
is  made. 

Insertion  of  the  Needle.  The  place  for  inserting  the 
needle  is  on  the  inner  side  of  the  palpating  finger,   i  cm. 


Figure  55 
Pterygomandibular  injection  of  left  side. 

over  the  last  molar.  Fig.  56.  The  student  will  at  first  be 
surprised  to  find  this  place  a  good  deal  further  to  the  out- 
side than  he  expected.  If  the  last  molars  have  been  lost, 
it  is  sometimes  difficult  to  determine  the  exact  position 
for  the  puncture.  Sometimes  there  is  a  good  deal  of  atro- 
phy of  the  jaw,  and  the  tendency  therefore  is  to  make  the 
injection  too  low.     It  is  better  to  err  in  the  other  direction. 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA 


119 


If  the  upper  teeth  are  present,  an  imaginary  line  may  be 
drawn  over  their  occlusal  surfaces.  The  place  where  this 
meets  the  internal  oblique  line,  with  the  mouth  opened  as 
wide  as  possible,  is  generally  the  right  location.  If  there 
are  no  back  teeth  in  either  jaw,  have  the  patient  open  the 
mouth  wide  and  estimate  the  location  by  dividing  the  dis- 


FlGURE    56 
Roentgen  picture,    showing   needle   inserted    for  the  pterygo- 
mandibular injection. 

tance  between  the  inferior  and  superior  alveolar  ridge  in  two. 
The  needle  is  inserted  one  cm.  above  this  point. 

The  syringe,  which  is  held  in  readiness,  is  taken  up  with 
the  right  hand  and  at  the  same  time  the  palpating  finger 
should  draw  the  mucous  membrane  to  the  outside.  This 
not  only  makes  the  puncture  easier,  but  also  makes  it  pos- 
sible to  change  the  position  of  the  needle  after  it  has  been 


I20  OILiL  ANESTHESIA 

inserted  by  moving  it  with  the  mucous  membrane  towards 
the  median  hne,  if  necessary.  Introduce  the  syringe  at  an 
acute  angle  to  the  inner  surface  of  the  ramus  by  placing 
the  barrel  between  the  cuspid  and  bicuspid  of  the  other 
side.  Puncture  the  mucous  membrane,  the  opening  of  the 
needle  pointing  toward  the  outer  side,  and  inject  a  few 
drops  to  anesthetize  the  superficial  structures. 

Advance  the  needle,  following  the  same  direction.  A 
fascia,  which  often  presents  considerable  resistance,  is  met 
next.  A  sharp  needle  penetrates  this  with  a  little  additional 
pressure,  and  then  comes  in  contact  with  solid  bone,  the  inter- 
nal oblique  line.  This  is  an  important  landmark  and  should 
be  reached  after  inserting  the  needle  about  5  mm.  If  it 
cannot  be  felt,  it  is  due  to  one  of  two  things,  either  the  needle 
has  been  inserted  too  far  medially,  or  else  the  direction 
is  not  correct,  in  which  case  the  barrel  of  the  syringe  should  be 
moved  still  further  back.  After  feeling  the  internal  oblique 
line,  the  direction  of  the  syringe  should  be  changed,  bring- 
ing it  more  towards  the  median  line,  until  it  is  almost  parallel 
with  the  ramus  (Fig.  54,  2  and  5).  If  it  is  desired  to 
anesthetize  the  lingual  nerve,  the  needle  should  be  inserted 
I  cm.,  when  about  ^  cc.  of  the  solution  should  be  injected. 

If  the  inferior  alveolar  nerve  is  also  to  be  anesthetized, 
the  needle  should  be  advanced  further.  It  is  well  to  make 
sure  of  the  proper  direction  by  occasionally  feeling  the 
bone.  Even  the  experienced  operator  should  not  neglect 
to  do  this,  to  avoid  failures  in  case  of  anatomical  variations. 
It  is,  however,  important  not  to  push  the  needle  underneath 
the  periosteum.  If  the  anterior  part  of  the  inner  surface  of 
the  ramus  presents  a  well-marked  convex  condition,  as  is 
often  found  in  heavy  people  with  thick,  solid  bones,  it  is 
often  necessary  to  draw  the  needle  back.  By  releasing  the 
mucous  membrane  and  moving  it  with  the  needle  towards 
the  median  line,  the  pterygomandibular  space  is  approached 
at   a  less   acute  angle,   the   needle   being   aimed   from    the 


SPECIAL   TECHNIQUE  OF  LOCAL   ANESTHESIA  121 

first  towards  the  center  of  the  ramus.  After  it  has  been  fully 
inserted  (Fig.  54,  3  and  6)  (in  children  correspondingly  less) 
make  sure  that  the  right  place  has  been  reached  by  again 
feeling  the  bone.  The  point  of  the  needle  should  now  be 
in  the  pterygomandibular  space,  just  above  the  lingula 
(Fig.  53)  where  the  main  part  of  the  solution  is  injected 
(i  J  cc.)  in  a  slow  and  even  manner,  gently  moving  the  syr- 
inge back  and  forth.     It  is  important  not  to  inject  while 


Figure  57 
Pterygomandibular  injection  on  the  right  side. 

inserting  the  needle  so  as  to  avoid  infiltration  of  the  muscle, 
and  also  reserve  a  larger  amount  for  the  final  injection,  which 
is  readily  taken  up  by  the  connective  tissue  of  the  pterygo- 
mandibular space. 

In  children  the  mandibular  foramen  lies  somewhat 
lower,  and  in  the  aged,  higher.  The  injection  should  be 
made  accordingly. 

Waiting  Period.  The  anesthesia  takes  effect  in  from 
10  to  20  minutes,  and  is  at  its  best  after  half  an  hour. 


122  ORAL   ANESTHESIA 

Symptoms  of  Anesthesia.  After  about  five  minutes  or 
earlier,  the  patient  feels  a  condition  in  the  tip  and  side  of 
tongue  and  the  corresponding  half  of  the  lower  lip,  which 
is  described  as  tingling,  hot,  cold,  hard,  stiff,  swollen,  or 
numb  sensation.  If  these  symptoms  do  not  appear  within  a 
reasonable  time,  another  injection  should  be  made. 

Area  Anesthetized.  By  blocking  the  inferior  alveolar 
nerve  the  following  parts  are  anesthetized:  externally  the 
lower  lip  and  the  region  of  the  corners  of  the  mouth  as  far 
back  as  the  mental  foramen;  internally  all  the  teeth  and 
the  bone  on  that  side,  also  the  gum  on  the  labial  side  from  the 
anterior  teeth  as  far  back  as  the  first  bicuspid.  Blocking 
the  lingual  nerve  in  addition  gives  anesthesia  of  the  tip  and 
side  of  the  tongue  and  lingual  part  of  the  gum. 

Communicating  and  Interlacing  Nerves.  When  oper- 
ating in  front  of  the  mouth,  the  nerve  of  the  other  side  has 
to  be  considered,  and  also  the  branches  of  the  cervical  plexus. 
The  buccinator  nerve  supplies  the  gum  on  the  buccal  side 
of  the  second  bicuspids  and  molars,  and  is  generally  not 
anesthetized  with  the  pterygomandibular  method. 

Duration  of  Anesthesia.  If  about  2  cc.  of  a  2  per  cent 
solution  is  injected,  the  anesthesia  usually  lasts  from  one 
to  one  and  a  half  hours.  If  more  time  is  required  for  the 
operation,  the  injection  should  either  be  repeated  after 
one  hour  or  else  4  cc.  should  be  injected  at  once,  when  it  will 
last  for  about  two  to  three  hours. 

Return  to  Normal.  The  anesthesia  wears  off  gradually 
through  absorption  of  the  anesthetic  solution. 

Failures  occur  if  the  needle  loses  contact  with  the 
inner  surface  of  the  ramus  and  the  solution  is  injected  into 
the  muscle;  if  the  needle  is  not  inserted  deep  enough;  or 
if  the  injection  is  made  too  low.  If  the  solution  does  not 
thoroughly  infiltrate  the  nerve,  the  parts  supplied  by  the 
central  fibers  may  not  become  entirely  anesthetized. 


SPECIAL    TECHNIQUE  OF   LOCAL   ANESTHESIA  123 

Mental  Injection 

For  the  Mental   Xerve  and  Anterior  Part  of  Inferior 
Alveolar   Nerve 

This  injection  is  not  often  used,  as  it  has  no  special 
advantages  and  the  same  parts  can  be  more  easily  and 
efficiently  anesthetized  by  means  of  the  pterygomandibular 
injection.  The  location  of  the  mental  foramen  is  variable, 
as  has  already  been  seen,  and  its  size  and  formation  varies 
greatly.  The  injection  is  used  to  anesthetize  the  mental 
nerve  where  it  leaves  the  bone,  as  well  as  to  produce  anes- 
thesia of  the  anterior  part  of  the  inferior  alveolar  nerve, 
supplying  the  incisor  teeth,  cuspid,  and  first  bicuspid. 

Instruments.  Use  syringe  No.  i  with  long  hub  and  42- 
mm.  needle. 

Landmarks.  The  mental  foramen  cannot  always  be 
readily  found.  It  lies  halfway  between  the  inferior  border 
of  the  mandible  and  the  gingival  margin.  The  teeth  serve 
usually  as  landmarks.  Its  location  is  either  anterior,  in- 
ferior or  posterior  to  the  apex  of  the  second  bicuspid.  The 
foramen  may  be  found  with  the  tip  of  the  palpating  finger. 

Technique.  If  it  is  intended  to  inject  the  solution  out- 
side the  foramen,  the  needle  can  be  inserted  about  i  cm. 
anteriorly.  If  the  injection  is  to  be  made  into  the  mental 
foramen  itself,  the  needle  should  be  inserted  posteriorly 
and  from  above  to  follow  the  direction  of  the  canal.  After 
the  foramen  has  been  located  and  the  mucous  membrane 
prepared  in  the  usual  manner,  place  the  tip  of  the  palpating 
finger  over  it  and  insert  the  needle  a  short  distance  anterior 
to  the  finger.  After  injecting  a  small  amount,  it  is  ad- 
vanced along  the  bone  until  the  point  is  felt,  when  i  cc.  of 
the  solution  is  injected  while  applying  pressure  with  the 
finger  tip.  If  we  depend  on  this  method  for  anesthesia  of 
the  anterior  branch  of  the  inferior  alveolar  nerve,  it  is 
necessary  to  promote  its  infiltration  into  the  canal  by  apply- 


124 


ORAL  ANESTHESIA 


ing  pressure  during  the  injection  and  several  minutes  after- 
wards. Better  results  can  be  attained  by  inserting  the 
needle  from  above  and  behind,  guiding  it  into  the  foramen 
for  about  5  mm.  One  cc.  is  then  injected  directly  into  the 
canal. 


Figure  58 
Mental  injection  on  right  side. 


Waiting  Period.  Anesthesia  usually  occurs  in  ten  min- 
utes. 

Symptoms  of  Anesthesia.  Numbness  of  the  lip  occurs 
as  in  the  previous  method,  this  being  due  to  the  blocking 


SPECIAL    TECHNIQUE  OF  LOCAL  ANESTHESIA 


125 


of  the  mental  nerve,  but  it  is  not  a  sign  that  the  teeth  in 
the  anterior  part  of  the  mandible  have  been  anesthetized. 

Area  Anesthetized.  The  lip,  anterior  part  of  the  gum, 
and,  if  the  canal  is  successfully  infiltrated,  the  teeth  anterior 
to  the  foramen  are  anesthetized.     The  lingual  part  of  the 


Figure  59 
Roentgen  picture,  showing  needle  inserted  formenlid  injection. 

gum  retains  its  sensation.  The  injection  is  generally  used 
on  both  sides  simultaneously,  to  get  anesthesia  of  the  an- 
terior part  of  the  lower  jaw.  It  may  also  be  used  in 
conjunction  with  the  pterygomandibular  injection  on  the  op- 


126  ORAL  ANESTHESIA 

posite  side  and  serves  to  block  the  communicating  nerves 
coming  from  the  other  side. 

Duration  of  the  Anesthesia.  The  duration  depends 
upon  the  amount  of  solution  which  penetrates  into  the 
mandibular  canal.     It  may  last  one  hour. 

The  Buccinator  Injection 

The  mucous  membrane  of  the  cheek  and  buccal  part 
of  the  gum  at  the  lower  jaw,  usually  as  far  forward  as  the 
second  bicuspid,  is  supplied  by  the  buccinator  nerve.  If 
an  operation  involves  these  parts,  either  infiltration  anes- 
thesia has  to  be  resorted  to  or  else  the  buccinator  nerve  has 
to  be  blocked.  Some  writers  claim  that  this  area  is  anes- 
thetized while  injecting  for  the  inferior  alveolar  nerve. 

Anatomical  Considerations.  The  buccinator  nerve  lies 
for  a  considerable  distance  at  the  anterior  aspect  of  the 
ramus  until  it  passes  into  the  cheek  at  the  level  of  the  parotid 
duct.  The  cheek  is  taken  between  the  thumb  and  index 
finger  and  extended  laterally  with  the  jaws  opened.  Insert 
the  needle  towards  the  ramus  and  inject  about  i  cc. 

Area  Anesthetized.  Mucous  membrane  of  cheek,  post- 
molar  triangle,  and  buccal  part  of  gum  in  lower  jaw. 

Sphenomaxillary  In j  e  ction 

For  the  Second  Division  of  the  Fifth  Nerve 

The  entire  upper  jaw  is  not  as  easily  anesthetized  as  the 
mandible  because  its  nerve  supply  is  not  as  conveniently 
situated  and  no  method  has  been  developed  so  far  which  is 
simple  and  gives  evenly  satisfactory  results.  There  is  not 
only  the  difficulty  of  reaching  the  maxillary  nerve  and 
inducing  anesthesia  of  all  its  branches,  but  even  if  it  could 
be  easily  accomplished  from  the  oral  cavity,  it  would  not  be 
practical  for  minor  dental  operations  on  account  of  producing 
numbness  of  parts  which  are  not  only  remote  from  the  field 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  127 


Figure  60 
Oblique  frontal  section  through  sphenomaxillary  fissure,  showing 
posterior  surface  of  maxillary  bone.  a.  Sphenoid  bone.  b.  Optic 
nerve,  c.  Ophthalmic  artery,  d.  Sphenoidal  sinus,  e.  Frontal, 
lacrimal,  trochlear,  nasociliary,  abducens,  occulomotor  nerves. 
f.  Sphenomaxillary  fissure,  g.  Sphenopalatine  ganglion,  h. 
Post.  sup.  alv.  nerves,  i.  Nasal  cavity,  j.  Posterior  palatine,  k.  an- 
terior palatine  nerve  and  artery.  1.  Internal  maxillary  artery,  m. 
post.  sup.  alveolar  artery,  n.  Anterior  palatine  nerve  on  palate,  o. 
Large  palatine  foramen,  p.  Buccal  branch,  q.  Masseter  m.  r. 
Parotid  gland,  s.  Zygomatic  arch.  t\  t^,  t^.  Temporal  artery. 
u.  Temporal  m.  v.  Branches  of  superficial  temporal  artery. 
\v,  y,  z.   Branches  of  facial  nerve. 

of  operation,  but  which  would  cause  disagreeable  sensations, 
such  as  numbness  of  the  soft  palate  and  uvula.  On  account 
of  this,  it  is  desirable  not  to  block  the  entire  maxillary  nerve 
where   it   emerges  from  the  foramen   rotundum,  but    at  a 


128  ORAL  ANESTHESIA 

place  as  far  peripheral  as  possible,  so  as  to  avoid  the  spheno- 
palatine ganglion  but  include  the  posterior  superior  alveolar 
nerve.  The  mucous  membrane  of  the  hard  palate  and 
gum  can  easily  be  taken  care  of  separately  by  blocking  the 
nerves  at  the  incisive  and  larger  palatine  foramina. 

Anatomical  Considerations.  The  maxillary  division,  after 
leaving  the  cranium  through  the  foramen  rotundum,  crosses 
the  sphenomaxillary  fossa.  Its  length  to  the  place  where 
it  enters  the  infraorbital  fissure  is  about  i  cm.  The  spheno- 
maxillary fossa  is  filled  with  connective  tissue,  and  externally 
is  bordered  by  the  parotid  gland.  It  contains  a  number  of 
vessels,  the  largest  being  the  infraorbital  artery.  Smaller 
branches  are  the  posterior  superior  alveolar  branches,  the 
sphenopalatine  branches,  and  several  veins  emptying  into 
the  pterygoid  plexus.  The  sphenopalatine  ganglion  lies 
directly  over  the  pterygopalatine  canal,  and  its  sensory 
branches  leave  the  maxillary  nerve  as  soon  as  the  latter 
enters  the  sphenomaxillary  fissure.  The  maxillary  nerve, 
after  leaving  the  fossa,  is  called  the  infraorbital  nerve  and 
for  its  first  course  runs  in  an  open  channel,  the  sulcus  in- 
fraorbitalis  on  the  floor  of  the  orbit,  the  continuation  of 
which  is  the  canal  of  the  same  name  (Fig.  i8).  The  parts 
supplied  by  all  the  superior  alveolar  branches  can  therefore 
be  anesthetized  by  blocking  the  nerve  where  it  enters  the 
sulcus,  avoiding  the  nasal  and  palatal  branches.  Here  the 
posterior  superior  alveolar  and  gingival  branches  are  given 
off.  The  middle  superior  alveolar  branch  usually  begins 
in  the  sulcus  infraorbitalis,  where  it  enters  a  canal  in 
the  outer  wall  of  the  antrum.  Sometimes,  however,  it  runs 
for  a  short  distance  over  the  zygomatic  surface  of  the  maxilla 
before  entering  a  special  foramen  anterior  to  and  above  the 
one  for  the  posterior  branch.  It  is,  therefore,  desirable  to 
reach  the  nerve  just  where  it  enters  the  sulcus  infraorbitalis. 

Instruments.  A  special  needle  is  required  for  this  in- 
jection.    It    should    be    larger     (22     gauge)     and    its    free 


SPECIAL   TECHNIQUE  OF  LOCAL   ANESTHESIA  129 

length,  from  hub  to  point,  should  be  4  cm.  Smith  has 
designed  a  special  needle  (Fig.  61)  for  this  purpose,  bent  at 
a  right  angle.  It  is  mounted  on  syringe  No.  2.  After 
giving  it  a  fair  trial,  I  found  that  I  could  do  better  with  the 
bayonet-shaped  attachment  of  new  construction  and  5  cm. 
needle  mounted  on  syringe  No.  i  (Fig.  27). 

Landmarks.  With  the  jaws  but  slightly  opened  and 
the  buccinator  muscle  relaxed,  the  cheek  can  be  sufficiently 
retracted  laterally  so  as  to  bring  into  plain  view  the  begin- 
ning of  the  zygomatic  process  on  the  maxillary  bone. 


Figure  61 
Luer  syringe  with  needle  for  intraoral  sphenomaxillary  injections 

Technique.  The  needle  is  inserted  high  up  in  the  re- 
flection of  the  mucous  membrane  at  the  concave  posterior 
surface  of  the  zygomatic  process  of  the  maxilla  over  the 
apices  of  the  second  molar,  the  opening  of  the  needle  directed 
towards  the  bone.  After  inserting  the  needle,  it  is  ad- 
vanced obliquely  upward  and  slightly  backward,  keeping 
in  close  contact  with  the  bone  covered  by  the  periosteum. 
A  few  drops  are  injected  after  the  i)uncture  is  made  and 
more  while  the  needle  advances.  After  it  is  inserted  about 
3  cm.  the  point  should  be  in  the  neighborhood  of  the  infra- 
orbital fissure,  where  the  remaining  part  of  the  solution  in 
the  syringe  containing  3  cc.  is  deposited. 


I30 


ORAL  ANESTHESIA 


The  solution  is  taken  up  freely  and  easily  by  the  con- 
nective tissue,  and  occasionally  may  be  so  extensively  dis- 
tributed that  it  affects  other  nerves,  especially  the  spheno- 
palatine ganglion  and  its  branches,  also  the  oculomotor  or 
abducens  nerve.  Smith,  making  this  injection  with  his 
specially  devised  needle,  anesthetizes  the  entire  second  di- 
vision.    He  inserts  his  needle  more  posteriorly  as  far  back 


Figure  62 
Sphenomaxillary  injection  with  new  bayonet  attachment. 


as  the  roots  of  the  third  molar  and  then  follows  a  more 
vertical  direction,  keeping  in  close  contact  with  the  perios- 
teum of  the  maxilla.  He  inserts  the  needle  3  cm.  and  in- 
jects 3  cc.  Stern  advocates  a  shifting  of  the  needle  for 
the  last  part  of  the  injection,  about  5  mm.  in  a  posterior 
direction  to  include  the  ganglion.  The  author,  however, 
prefers  the  extraoral  method,  if  the  entire  maxillary  division 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  131 

is  to  be  anesthetized.  One  should  remember  to  keep 
close  to  the  zygomatic  surface  of  the  maxilla  to  avoid  injury 
of  a  vessel,  as  this  may  cause  the  formation  of  a  hematoma. 

Waiting  Period.  Generally  about  fifteen  minutes,  but  the 
time  is  dependent  upon  how  close  to  the  nerves  the  solu- 
tion is  deposited. 

Symptoms  of  Anesthesia.  The  symptoms  are  important, 
as  they  give  an  idea  of  the  success  of  the  injection  and  the 
extent  of  the  anesthesia.  If  the  infraorbital  region  of  the 
skin  and  half  of  the  upper  lip  feels  somewhat  numb,  it  is  a 
sign  that  the  infraorbital  nerve  and  its  dental  branches  have 
been  successfully  blocked.  If  the  corresponding  half  of  the 
nose  and  the  palate  feel  numb,  it  is  a  sign  of  anesthesia  of  the 
sphenopalatine  ganglion  and  its  branches. 

Area  Anesthetized.  If  successful,  all  the  upper  teeth  on 
one  side  and  the  buccal  and  labial  part  of  the  gum  should 
be  anesthetized.  Occasionally,  however,  only  the  superior 
alveolar  branches  may  be  reached,  and  at  times  the  solution 
may  infiltrate  the  sphenopalatine  ganglion  and  its  nasal 
and  palatal  branches.  The  symptoms  of  anesthesia  and 
testing  of  the  various  parts  will  give  the  desired  information. 

Communicating  Nerves.  The  branches  which  have  not 
become  anesthetized  by  the  primary  injection  have  to  be 
taken  care  of  separately. 

Duration  of  Anesthesia.  The  time  on  which  we  can 
depend  for  painless  operating  is  from  one  to  one  and  one  half 
hours. 

Failures  and  Undesirable  Symptoms.  On  account  of 
the  variability  of  the  anatomical  relations,  success  is  not 
as  certain  as  with  the  other  methods.  The  technique  is 
also  more  difficult  because  of  the  inconvenient  location  of 
the  nerve.  If  the  ganglion  or  the  oculomotor  and  abducens 
nerve  is  anesthetized,  difficulty  in  swallowing,  or  ocular 
disturbances  may  be  produced  (see  also  under  extraoral 
maxillary  injection). 


132 


ORAL   ANESTHESIA 


The  Zygomatic  Injection 

For  the  Posterior  Superior  Alveolar  Nerves 
This  injection,  which  is  also  called  tuberosity  injection^ 
is  very  useful.  Its  aim  is  to  block  the  posterior  superior 
alveolar  branches  and  in  a  large  number  of  cases  the  middle 
superior  alveolar  branch.  It  is  a  modification  of  the  spheno- 
maxillary injection. 


FiGUEE    63 

Infratemporal  surface  of  the  maxilla.  The  posterior  superior 
alveolar  branches  are  shown  entering  the  foramina.  One  branch 
is  a  gingival  branch. 

Anatomical  Considerations.  The  posterior  superior  al- 
veolar branch  descends  on  the  zygomatic  surface  of  the 
maxilla  in  an  almost  vertical  direction.  It  may  be  ac- 
companied for  a  short  distance  by  the  middle  superior 
alveolar  nerve.  The  former  enters  its  foramen  at  about  the 
middle  of  the  surface;   the  latter  much  higher  up. 


SPECIAL    TECHNIQUE  OF  LOCAL   ANESTHESIA  133 

Instruments.  Syringe  No.  i  with  a  42-mm.  platinum 
needle  is  used.  The  needle  may  be  slightly  curved  previous  to 
sterilizing  it.  Some  operators  find  it  more  convenient  to 
mount  it  with  the  bayonet  attachment. 

Landmarks.  Palpate  the  zygomatic  process  of  the  max- 
illa with  jaws  opened  halfway  and  cheek  relaxed. 

Technique.  The  needle  is  inserted  opposite  the  roots 
of  the  second  molar,  as  high  up  in  the  reflection  of  the  mu- 
cous membrane  as  possible,  the  opening  directed  towards  the 
bone.  Follow  an  upward,  backward,  and  inward  direction, 
keeping  in  close  contact  with  the  periosteum  and  depositing 
the  solution  while  advancing.  The  path  of  the  needle 
crosses  the  posterior,  superior  alveolar  and  gingival  branches 
and  often  reaches  the  middle  superior  alveolar  branch. 

Waiting  Period.     Anesthesia  occurs  in  ten  minutes. 

Symptoms  of  Anesthesia.  Symptoms  are  usually  absent 
from  this  injection. 

Area  Anesthetized.  The  posterior  teeth  and  corres- 
ponding alveolar  part  of  the  bone  and  buccal  gum  of  the 
upper  jaw  are  anesthetized.  The  extent  depends  some- 
what on  whether  both  the  posterior  and  middle  alveolar 
nerves  have  been  blocked  or  whether  the  posterior  one  alone 
has  been  affected,  in  which  case  it  results  generally  in  an- 
esthesia of  the  three  molar  and  two  bicuspid  teeth.  The 
gingival  branch,  however,  reaches  usually  only  as  far  for- 
ward as  the  second  bicuspid. 

Anastomosing  and  Communicating  Nerves.  It  is  im- 
portant to  keep  in  mind  that  the  posterior  middle  and 
anterior  alveolar  branches  form  an  extensive  plexus,  the  su- 
perior dental  plexus,  and  that  impulses  and  sensations  may 
be  conveyed  in  two  directions.  With  the  posterior  alveolar 
branch  blocked,  the  second  and  third  molars  are  as  a  rule 
completely  anesthetized,  but  pain  from  the  first  molar  may 
still  be  conveyed  by  way  of  anastomoses  with  the  middle 
alveolar  branch.     The  palatal  part  of  the  gum  has  to  be 


134 


ORAL  ANESTHESIA 


FiGUEE    64 

Zygomatic  injection  on  right  side. 

taken  care  of  separately  by  either  the  infiltration  or  conduc- 
tion method  for  the  palatal  branches. 

Duration  of  Anesthesia.  Anesthesia  usually  lasts  about 
three  quarters  of  an  hour. 

Failures  are  due  either  to  improper  technique  or  to  ana- 
tomical variations. 

Infraorbital  Injection 

In  the  Anterior  Superior  Alveolar  and  Terminal 
Branches  of  the  Infraorbital  Nerve 

With  this  method  anesthesia^^'of  the  terminal  branches 
of  the  infraorbital  nerve,  the  palpebral,  the  nasal  and  labial 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA 


^iS 


Roentgen  picture,  showing  needle  inserted  for  zygomatic 
injection. 

nerves  is  induced.  It  is,  however,  more  frequently  employed 
to  anesthetize  the  anterior  superior  alveolar  nerve.  As  it 
is  impossible  to  insert  the  needle  into  the  canal  except  by 
the  extraoral  method,  it  is  necessary  to  depend  on  infiltra- 
tion of  the  solution  through  the  foramen  into  the  canal,  as 
far  back  as  is  necessary  to  reach  the  anterior  alveolar  branch. 
This  injection  has  not  become  very  popular,  as  many  patients 
object  to  the  slight  swelling  caused  by  the  infiltration. 

Instruments.      Use    the   42-mm.    needle    mounted   with 
the  long  hub  on  syringe  No.  i. 


136 


ORAL  ANESTHESIA 


Landmarks.  Palpate  the  inferior  border  of  the  orbit. 
The  infraorbital  foramen  lies  a  few  millimeters  below  on  the 
anterior  surface  of  the  maxilla  and  can  be  easily  located 
with  the  finger  tip. 


Figure  66 
Infraorbital  injection  on  right  side. 


Technique.  The  index  finger  should  be  placed  over  the 
infraorbital  foramen  when  the  operator's  position  is  in  front 
of  the  patient.  When  the  position  is  at  the  side  of  the 
chair,  the  thumb  is  more  convenient.     With  another  finger 


SPECIAL    TECHXIOL'E  OF   LOCAL   ANESTHESIA 


1.37 


retract  the  upper  lip  so  as  to  expose  the  entire  canine  fossa, 
where  the  needle  should  be  injected  as  high  up  as  possible. 
Advance  until  it  is  felt  under  the  palpating  finger.  Some- 
times it  is  necessary  to  inject  a  small  amount  to  detect  the 


Figure  67 
Roentgen  picture,  showing  needle  inserted  for  infraorbital  in- 
jection. 


location  of  the  point  of  the  needle.  Insert  the  needle  down 
to  the  bone  and  compress  the  soft  tissue  over  the  foramen, 
while  making  the  injection,  so  as  to  force  the  solution  into 


138  ORAL  ANESTHESIA 

the  infraorbital  canal,  where  the  anterior  superior  alveolar 
nerve  will  be  anesthetized.     Use  i  to  i|  cc.  of  the  solution. 

Waiting  Period.     About  ten  minutes. 

Symptoms  of  Anesthesia.  Numbness  in  upper  lip,  lower 
eyelid,  and  side  of  nose.  This,  however,  is  only  a  sign  that 
the  terminal  branches  have  been  anesthetized  and  is  not  an 
indication  of  anesthesia  of  the  teeth. 

Area  Anesthetized.  Besides  the  external  tissues  just 
mentioned,  anesthesia  is  produced  in  the  central  and  lateral 
incisors,  and  sometimes  the  cuspid. 

Communicating  and  Anastomosing  Nerves.  Anastomo- 
ses from  the  opposite  side  as  well  as  from  the  posterior 
branches  of  the  infraorbital  nerve  should  be  kept  in  mind. 
The  palatal  part  of  the  gum  is  supplied  by  the  nasopalatine 
nerve  and  therefore  needs  an  additional  injection. 

Duration  of  Anesthesia.  About  three  quarters  of  an 
hour. 

Incisive  Injection 

For  the   Nasopalatine   Nerve 

This  method  is  used  to  anesthetize  the  anterior  part  of 
the  palate  and  palatal  gum.  The  injection  is  made  into 
the  foramen,  which  usually  is  of  large  size. 

Instruments.     Syringe  No.  i  with  long  or  short  needle. 

Technique.  Insert  the  needle  in  the  median  line,  di- 
rectly behind  the  central  incisors.  If  the  bone  is  followed/ 
the  needle  will  be  conducted  into  the  foramen,  where  a  few 
drops  (about  J  cc.)  only  are  necessary  to  produce  anesthesia. 

Area  Anesthetized.  The  palatal  gum  and  anterior  part 
of  the  hard  palate  as  far  back  as  the  cuspids. 

Waiting  Period.     Anesthesia  occurs  almost  at  once. 

Duration  of  Anesthesia.  This  varies  according  to  amount 
injected.     One  quarter  cc.  lasts  about  one  hour. 


SPECIAL  TECHNIQUE  OF  LOCAL  ANESTHESIA  139 

Palatine  Injection 

For  the  Anterior  Palatine  Nerve 

This  injection,  as  the  preceding  one,  gives  anesthesia 
of  only  the  soft  tissues,  namely  the  mucous  membrane 
covering  the  posterior  part  of  the  palate,  and  the  palatal  part 
of  the  alveolar  process. 

Anatomical  Considerations.  The  location  of  the  larger 
palatine  foramen  varies  according  to  the  age  of  the  patient, 
as  has  been  described  in  the  chapter  dealing  with  the  ana- 
tomical structure  of  the  jaws. 

Instruments.  Syringe  No.  i  can  be  used  with  either  the 
long  or  the  short  needle. 

Technique.  Insert  the  needle  about  i  cm.  above  the 
gingival  margin  on  the  palatal  side  of  the  last  erupted  molar 
or,  if  extracted,  the  position  it  occupied.  The  place  should 
be  selected  so  that  the  needle  can  be  advanced  toward  the 
palatine  foramen  in  a  straight  line.  After  the  foramen  has 
been  reached,  about  |  cc.  or  less  of  the  anesthetic  solution 
should  be  injected. 

Area  Anesthetized.  This  injection  anesthetizes  the  lat- 
eral half  of  the  posterior  two  thirds  of  the  palate  approxi- 
mately from  the  cuspid  back. 

Duration  of  Anesthesia.     About  one  hour. 

Undesirable  Symptoms.  If  too  much  of  the  solution 
is  injected,  anesthesia  of  the  palatine  nerve  supplying  the 
soft  palate  results,  which  is  uncomfortable  and  often  dis- 
tressing to  the  patient. 

The  following  tables  give  general  information  assisting 
in  the  proper  selection  of  the  infiltration  or  conduction 
methods,  as  well  as  the  amounts  to  be  injected. 


I40 


ORAL  ANESTHESIA 


INFILTRATION   ANESTHESIA   FOR   THE   TEETH   ONLY 


I  MAXILLA 


BUCCAL 


LABIAL 


BUCCAL 


*  NOT  ALWAYS  SUCCESSFUL 
ON  ACCOUNT  OF  THICKNESS 
OF  BONE. 


BUCCAL 


(ftOT  successful) 


flMANDlBULA 


LABIAL 


fl>.cd        flkc<: 


BUCCAL 


(not  successful) 


nm.  in  m.  ub    ib     c. 


L  .     c.    c.     L . 

(not  needed.) 


C.     IB.  IB.     IM.  in.  ITM. 


LINGUAL 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  141 

INFILTRATION   ANESTHESIA   FOR   THE   TEETH   AND    SOFT   TISSUES 


IMAXILLA 


BUCCAL 


LABIAL 


BUCCAL 


EM  m*  m*  15     IB      c     L      c      c      L     c      IB     IB    in*  m*  im 


PALATAL 


n  NAIVDIBULA 


*  NOT  ALWAYS  SUCCESSFUL 
ON  ACCOUNT  OF  THICKNESS 
or  BONE. 


BUCCAL 


LABIAL 


BUCCAL 


(not  successful) 


in    m   \n    ib    ib    c 


LINGUAL 


[not         successful) 


C      IB     IB     m  in  IK 


142 


ORAL  ANESTHESIA 


CONDUCTION  ANESTHESIA   FOR   THE   TEETH    ONLY 


I.MAX1LLA 


RIGHT  RICHT  UtFT  LEFT 

ZYGOMATIC      INFRAORBITAL    INFRAORBITAL    ZYGOMATIC 


kl^.IM.  IM.  IB.  IB.     C.    L.      C.     G.    L.      C.     IB.  IB.  IM.  IM.JnM. 


n.MANDIBUlA 


RIGHT  LZTT  RIGHT  LEFT 

PTERYGOMANDIBULAR     MENTAL  FORAMEN  MENTAL  FORAMEN        PTERYGOMANDIBULAR 


■ALL  MANDIBUUR  tee™ 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  143 

CONDUCTION   ANESTHESIA   FOR   THE   TEETH  AND    SOFT   TISSUES 

I.  MAXILLA 


RIGHT  RIGHT  RIGHT  LE.FT  LEFT  LEFT 

SPHENO-mxiLlARY  ZYGOMATIC    [NFRAORBITAL      INFRAORBITAL     lYGOMAlJC     SPBENQ-MAiUllAKY 


OK 

ENTIRE    NAXILLA 


RIGHT 
PTERreOMANDrBULAR 
AND  LINGUAL 


n.MANDIBULA 


LEFT 
PTERYGOMANDIBULAR 
AND    ilNGUAL 


144  ORAL  ANESTHESIA 

Extraoral  Methods  of  Conduction  Anesthesia 

Extraoral  injections  are  indicated  in  all  cases  in  which 
the  intraoral  methods  are  inadvisable  on  account  of  path- 
ological changes  in  the  regions  where  injections  should  be 
made.  In  cases  of  fractures,  bullet  wounds,  and  injuries 
which  prevent  the  opening  of  the  mouth,  or  render  manipu- 
lation of  the  lips  and  cheeks  painful,  the  extraoral  injections 
are  especially  indicated.  Also  in  cases  of  extensive  opera- 
tions, such  as  excisions  of  the  upper  or  lower  jaw. 
Extraoral  are  not  more  difficult  than  intraoral  injections, 
and  it  is  principally  a  psychic  cause  which  prevents  their 
more  extensive  use,  as  the  dentist  and  even  the  oral  sur- 
geon hesitates  to  involve  parts  which  are  outside  the  oral 
cavity  and  seemingly  have  nothing  to  do  with  his  field  of 
work.  These  methods,  however,  are  more  than  justified 
in  extensive  operations  because  with  them  a  much  larger 
area  can  be  anesthetized  and  the  operative  procedure  may 
be  conducted  aseptically.  The  danger  of  infection  of  deeper 
areas  is  reduced,  as  aseptic  measures  are  more  readily  con- 
trolled externally  than  within  the  mouth.  However,  it  is 
important  to  warn  all  operators  that  extraoral  injections 
must  be  strictly  aseptic,  as  infections  from  them  are  more 
dangerous  than  those  from  intraoral  injections  on  account 
of  their  greater  depth  and  closer  proximity  to  the  brain. 

Extraoral  Mandibular  Injections 

For  the  Entire  Third  Division  of  the  Trigeminal 

Nerve 

Anesthesia  of  the  mandible  can  be  accomplished  suc- 
cessfully by  injecting  into  the  pterygomandibular  space  by 
the  intra-  and  extraoral  methods.  The  mandibular  injection 
is  indicated  for  operations  on  the  ramus,  especially  the  su- 
perior part;  also  if  the  pterygomandibular  injection  is  con- 
traindicated  on  account  of  pathological  conditions. 


SPECIAL  TECHNIQUE  OF  LOCAL  ANESTHESIA  145 

Instruments.  Use  syringe  No.  2  with  a  steel  needle  6 
to  8  cm.  long  and  a  rubber  disc  placed  so  as  to  indicate 
5  cm.  from  point  of  needle. 


Figure  68 
Frontal  section  through  foramen  ovale  showing  structures  to  be 
pierced  by  needle  to  reach  the  mandibular  nerve,  a.  Insula. 
b.  Dura  mater,  c.  Temporal  m.  d.  INIeningeal  a.  e.  Zy- 
gomatic process,  f.  Internal  maxillary  a.  g.  External  ptery- 
goid m.  h.  Masseter  m.  i.  Coronoid  process  of  mandible. 
j.  Claustrum.  k.  Corpus  nuclei  caudati.  1.  Putanen.  m. 
Globus  pallieus.  n.  Tractus  opticus,  o.  Oculomotor  nerve,  p. 
Trochlear  nerve,  q.  Trigeminal  ganglium.  r.  Cavernous  sinus. 
s.  Abducens  nerve,  t.  Pharyngeal  recess,  u.  Auditory  tube. 
V.   Mandibular  nerve,     w.   Levator  palatine  m. 

Landmarks.  A  line  drawn  from  the  zygomatic  angle 
to  the  tragus  of  the  ear  is  divided  into  halves  and  at  the 
dividing  point,  just  below  the  inferior  border  of  the  zygo- 
matic arch,  is  the  place  for  the  insertion  of  the  needle. 

Preparing    the    Site    of    Injection.     Disinfect    the    skin 


146 


ORAL  ANESTHESIA 


where  the  injection  is  to  be  made,  as  described  in  a  previous 
chapter.  Use  a  small  syringe  with  fine  needle  to  infiltrate 
the  skin  with  the  previous  use  of  the  ethyl  chlorid  spray  if 
necessary. 


Figure  69 
Landmarks  to  find  place  for  inserting  the  needle  for  the  extra- 
oral  mandibular  injection. 

Technique.     Insert  the  needle  and  advance  in  a  slightly 
upward  direction.     The  needle  passes  anterior  to  the  neck 


SPECIAL  TECHNIQUE  OF  LOCAL  ANESTHESIA 


147 


of  the  condyle  and  below  the  zygomatic  arch.  A  few  drops 
may  be  injected  at  once,  but  no  more  should  be  injected 
until  the  nerve  is  reached,  as  the  needle  transverses  several 
muscles  (see  Fig.  68).     After  advancing  to  a  depth  of  3  to 


FiGUKE    70 

Needle  inserted  for  the  extraoral  mandibular  injection. 

4  cm.  the  point  of  the  needle  should  strike  the  smooth  infra- 
temporal surface  and  be  carried  along  for  one  more  cm.  until 
the  mandibular  nerve  is  reached,  when  the  patient  notices 


148  ORAL  ANESTHESIA 

suddenly  a  radiating  pain  in  the  region  supplied  by  it.  In- 
ject from  2  to  5  cc. 

Waiting  Period.  Five  to  twenty  minutes  may  elapse 
before  anesthesia  is  complete,  depending  on  the  proximity 
of  the  injection  to  the  nerve. 

Symptoms  of  Anesthesia.  The  same  as  in  the  pterygo- 
mandibular injection. 

Area  Anesthetized.  Teeth  and  bone  of  the  mandible, 
lower  lip,  chin,  corner  of  the  mouth,  lower  part  of  the  cheek 
and  temporal  region. 

Communicating  Nerves.  Branches  of  the  cervical  plexus 
and  the  mandibular  nerve  from  the  other  side  are  to  be  con- 
sidered when  preparing  for  an  extensive  operation. 

Duration  of  Anesthesia.  The  anesthesia  lasts  from  two 
to  three  hours,  depending  on  the  amount  injected. 

Extraoral  Pterygomandibular  Injection 

For  the  Inferior  Alveolar   Nerve 

This  is  rhade  into  the  same  region  as  the  intraoral  in- 
jection; namely,  the  pterygomandibular  space.  It  is  in- 
dicated whenever  the  intraoral  method  cannot  be  used,  as 
is  often  the  case  in  fractures  of  the  mandible  and  trismus 
of  the  muscles  of  mastication. 

Instruments.  Use  syringe  No.  2  with  a  steel  needle  6  to 
8  cm.  long  and  a  rubber  disc  placed  5  cm.  from  point  of 
needle. 

Landmarks.  A  line  is  drawn  from  the  tragus  of  the 
ear  to  a  point  marked  by  the  anterior  margin  of  the  masseter 
muscle  and  the  lower  border  of  the  mandible.  The  point 
where  the  line  is  divided  in  halves  marks  the  projection  of  the 
mandibular  foramen  upon  the  skin. 

Technique.  Position  of  left  hand  for  the  injection  on 
the  right  side:  Place  index  finger  behind  and  parallel  with 
the  posterior  border  of  the  ramus,  the  thumb  in  the  same 
direction,  its  tip  touching  the  lower  border  of  the  ramus. 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA 


149 


Position  of  the  left  hand  for  injection  on  the  left  side: 
The  left  arm  is  passed  around  the  patient's  head,  the  thumb 
is  placed  behind  the  posterior  border  of  the  ramus  pointing 
downwards  and  the  index  finger  bent  around  the  angle  of 


FiorKK  71 
Landmarks  U;  determine  the  location  ol"  the  maiuHluilar  toramcn. 

the  ramus.  The  head  is  bent  towards  the  opposite  side. 
The  dismounted  needle  is  now  inserted  at  the  inner  side 
of  the  lower  border  of  the  mandible,  2  cm.  anterior  to  the 
angle  of  the  ramus.  Advance  in  a  parallel  direction  to  the 
posterior  border  of  the  ramus,  marked  on   the  left  side  by 


ISO 


ORAL  ANESTHESIA 


the  thumb  and  on  the  right  side  by  the  index  finger.  The 
pterygomandibular  space  is  about  4  cm.  from  the  point  of 
insertion  of  the  needle,  and  as  the  direction  of  the  needle  is 
parallel  to  the  nerve,  it  is  of  no  consequence  if  the  needle  is 
inserted  a  little  too  far.     Inject  2  cc. 


FlGUKE    72 

Inserting  needle  on  right  side  for  extraoral  pterygo- 
mandibtilar  injection. 

Waiting  Period.  Anesthesia  takes  effect  in  fifteen  min- 
utes. 

Symptoms  of  Anesthesia.  Numbness  of  the  lip  is  felt 
about  five  minutes  after  the  injection. 

Area  Anesthetized.  The  lower  teeth  and  jaw  on  the 
side  injected,  the  lower  lip  and  anterior  part  of  gum. 

Communicating  Nerves.  The  inferior  alveolar  nerve 
and  the  mental  and  lingual  nerves  of  both  sides  communicate 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  151 

freely  in  the  anterior  part  of  the  lower  jaw.  If  anesthesia  of 
the  lingual  nerve  is  required,  it  must  be  done  separately. 
This  can  be  accomplished  in  two  ways,  first  by  withdrawing 
the  needle  about  i  cm.  and  reinserting  it  in  a  vertical  direc- 
tion to  the  inferior  border  of  the  mandible.  This  brings  it 
further  forward.     Second,  by  inserting   the    needle   5   cm., 


Figure  73 
Roentgen  picture,  showing  needle  inserted  for  extra- 
oral  pterygomandibular  injection. 

which  carries  it  higher  and  near  the  place  where  the  inferior 
alveolar  and  lingual  nerves  divide. 

Duration  of  Anesthesia.  Same  as  for  the  intraoral 
method;  that  is,  about  one  hour  if  2  cc.  are  injected. 

Failures.  The  advance  of  the  needle  may  find  bony 
resistance  at  a  depth  of  3  cm.  This  comes  from  wrong 
direction  of  the  needle  point,  striking  a  well-marked  internal 


ORAL  ANESTHESIA 


152 

oblique  line.  The  needle  may  strike  bone  at  once,  which 
may  indicate  a  well-marked  protuberance  for  the  attach- 
ment of  the  pterygoid  muscle. 


Figure  74 
Landmarks  to  find  point  where  to  insert  needle  for  extraoral 
maxillary  injection. 

Extraoral  Maxillary  Injection 

For  the  Entire  Second  Division  of  the  Trigeminal 

Nerve 

Considerable  progress  has  been   made   in   the   develop- 
ment of  intraoral  conduction  methods  for  the  upper  jaw, 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  153 

with  the  aim  of  anesthetizing  a  larger  area  with  a  small 
number  of  injections.  However,  the  extraoral  method  is 
more  satisfactory  for  extensive  surgical  operations  than  intra- 
oral injections  if  the  entire  second  division  is  to  be  anes- 


I'lGURE    75 

Inserting  needle  for  the  maxillary  injection. 

thetized.  By  the  extraoral  path  the  sphenomaxillary  fossa 
can  be  reached  directly,  but  the  greatest  advantage  Hes 
in  the  possibility  of  inserting  the  needle  in  a  place  remote 
from  the  field  of  operation,  and,  in  extensive  lesions,  outside 
the  diseased  zone. 


154  ORAL  ANESTHESIA 

Anatomical  Considerations.  The  sphenomaxillary  fossa 
has  already  been  described  under  the  heading  of  the  intraoral 
sphenomaxillary  injection.  The  only  structures  which  are 
penetrated  by  the  needle  are  the  skin  and  buccinator  muscle. 
(See  also  Fig.  60.) 

Instruments.  Use  syringe  No.  2  with  a  steel  needle  6  to 
8  cm.  long  and  a  rubber  disc  placed  5  cm.  from  point  of 
needle. 

Landmarks.  Palpate  the  superior  border  of  the  zygo- 
matic arch  and  find  the  place  where  it  forms  a  right  angle 
with  the  superior  margin  of  the  orbit.  This  is  called  the 
"  zygomatic  angle."  From  this  point,  draw  a  vertical  line 
downwards  and  the  point  for  insertion  of  the  needle  is  about 
J  cm.  below  the  place  where  this  meets  the  inferior  border 
of  the  zygomatic  arch. 

Technique.  With  the  teeth  in  occlusion  insert  the  needle 
with  syringe  mounted.  A  few  drops  are  injected  under 
the  skin.  After  advancing  in  a  vertical  direction  to  the 
cheek  for  2  to  3  cm.,  the  maxillary  tuberosity  is  struck.  If 
only  the  posterior  molars  are  to  be  anesthetized,  the  in- 
jection can  be  made  here.  If  the  whole  upper  jaw  is  to  be 
anesthetized,  the  needle  is  advanced  in  the  same  direction 
to  the  sphenomaxillary  fossa.  Sometimes  it  is  necessary 
to  direct  the  needle  a  little  further  backward  to  pass  by  the 
tuberosity  which  is  felt  for  orientation.  After  a  further 
advance  of  2  cm.,  bony  resistance  is  again  felt  when  the 
point  of  the  needle  strikes  the  inferior  part  of  the  anterior 
surface  of  the  larger  wing  of  the  sphenoid  bone,  just  below 
the  foramen  rotundum.  The  depth  at  this  place  is  about 
5  cm.  One  to  two  cc.  are  injected.  The  injection  is  made 
purposely  below  the  foramen  to  keep  away  from  the  nerves 
supplying  the  eye  (see  Fig.  60). 

Waiting  Period.  Complete  anesthesia  usually  occurs 
in  from  ten  to  fifteen  minutes. 


SPECIAL  TECHNIQUE  OF  LOCAL  ANESTHESIA  155 

Symptoms  of  Anesthesia.  After  about  five  minutes 
the  patient  feels  numbness  in  the  nose,  and  sometimes 
in  the  upper  Up,  but  the  symptoms  are  much  less  marked 
than  in  the  lower  jaw. 

Area  Anesthetized.  Practically  all  the  parts  suppHed 
by  the  maxillary  division   are  anesthetized,  the    maxillary 


Figure  76 
Skull,  showing  direction  of  needle.   Note  the  sup.  alv.  nerve 
branches. 

bone,  the  teeth,  the  gum,  half  of  the  palate  and  upper  lip, 
the  anterior  part  of  the  cheek,  the  skin  of  the  nose,  the 
antrum  and  part  of  the  nasal  cavity. 

Anastomosing  and  Communicating  Nerves.  Branches 
from  the  other  side  have  to  be  considered  and  the  facial 
branches  of  other  divisions  of  the  trigeminal  nerve. 

Duration  of  the  Anesthesia.  The  anesthesia  lasts  from 
two  to  three  hours. 

Undesirable  Symptoms.  Anemia  in  the  region  of  the 
infraorbital  artery  sometimes  causes  circumscribed  blanch- 
ing of  part  of  the  cheek  supplied  by  it.  This  is  of  no  conse- 
quence.    Diffusion   of  the  solution  into  the  orbit  is  liable 


156 


ORAL  ANESTHESIA 


to  occur,  causing  ocular  disturbances  of  short  duration. 
The  oculomotor  or  abducens  nerve  may  be  infiltrated, 
causing  double  sight,  weakness  in  the  upper  eyelid,  dilation 
of  the  pupil,  and  if  some  of  the  accompanying  vessels  are  af- 
fected, anemia  of  the  eyelids  will  be  observed.     Sometimes 


Figure  77 
Inserting  needle  for  the  extraoral  infraorbital  injection. 

anesthesia  of  the  soft  palate  gives  difficulty  in  swallowing. 
All  these  complications,  which  occasionally  accompany  the 
anesthesia,  last  from  fifteen  minutes  to  two  hours  and  are 
not  serious,  merely  inconveniencing  the  patient  for  a  short 
time.  The  patient  should  be  told  that  these  conditions 
occur  at  times  and  that  they  are  to  be  disregarded.  As 
this  method  is  only  used  for  operations  of  a  serious  and 
extensive  nature,  the  occasional  occurrence  of  complications 


SPECIAL   TECHNIQUE  OF  LOCAL  ANESTHESIA  157 

can  be  considered  a  small  factor  compared  with  the  advan- 
tage of  positive  asepsis  and  the  disadvantages  of  general 
anesthesia  for  such  operations  in  the  mouth. 


Figure   78 
Roentgen  picture,  showing  needle  inserted  into  the  infraor- 
bital canal. 

Extraoral  Infraorbital  Injection 

For  the  Anterior  Superior  Alveolar  and  Infraorbital 

Nerve 
The  disadvantage  of  the  intraoral  method  for  the  infra- 
orbital injection  is  that  the  needle  cannot  be  introduced 
directly,  and  that  the  success  depends  on  infiltration  of  the 
canal.  Entrance  to  the  foramen  is  especially  important 
if  alcohol  injections  are  to  be  used  for  the  relief  of  neuralgic 
pain. 


158  ORAL  ANESTHESIA 

Anatomical  Considerations.  The  direction  of  the  in- 
fraorbital canal  varies  considerably.  Its  course  is  quite 
frequently  curved,  so  that  a  needle  cannot  be  inserted  to 
any  great  extent.  Its  direction  is  generally  slightly  upward 
and  outward.     Sometimes  there  are  accessory  foramina. 

Instruments.  Syringe  No.  i  may  be  used  with  the  42- 
mm.  iridio-platinum  needle.  The  syringe,  however,  should 
not  be  entirely  filled,  so  that  after  inserting  the  needle  to  the 
desired  point,  the  piston  may  be  drawn  back,  to  make  sure 
that  the  needle  has  not  been  inserted  into  a  vessel.  If 
syringe  No.  2  with  a  detachable  needle  is  used,  it  should  be 
of  small  calibre  (25  gauge)  and  made  of  iridio-platinum,  which 
is  flexible. 

Landmarks.  The  infraorbital  foramen  can  be  easily 
palpated  below  the  inferior  border  of  the  orbit. 

Technique.  The  needle  is  inserted  directly  into  the  infra- 
orbital foramen  from  the  surface  of  the  previously  prepared 
skin  for  about  ij  cm.  It  is  important  to  avoid  pushing 
the  needle  into  a  vessel.  (See  Page  161.)  One  and  a  half  cc. 
are  injected  with  even  pressure. 

Waiting  Period.  The  anesthesia  usually  occurs  in  a 
very  short  time. 

Area  Anesthetized.  Same  as  in  the  intraoral  method; 
namely,  the  upper  incisor  teeth,  labial  part  of  gum,  anterior 
part  of  maxillary  sinus,  and  the  area  supplied  by  the  palpe- 
bral, nasal  and  labial  branches  of  the  infraorbital  nerve. 

Duration  of  Anesthesia.  In  this  method  the  results 
are  quicker  and  more  lasting,  as  the  infiltration  of  the 
anesthetic  solution  through  the  infraorbital  foramen  is  not 
depended  upon  as  in  the  intraoral  method. 


PART  VII 

ILL   EFFECTS,   FAILURES,    ACCIDENTS,   AND 
POSTOPERATIVE   SEQUELAE 

111  Effects 

Px\IN  may  be  caused  by  injecting  solutions  which  are  not 
isotonic,  from  too  rapid  injecting  or  from  the  injection 
of  solutions  which  are  either  too  hot  or  cold.  Drugs  such 
as  thymol,  carboHc  acid,  etc.,  cause  pain,  as  demonstrated 
by  Seidel,  who  found  by  using  the  velum  test  on  the  skin 
of  his  arm  that  antiseptics  added  to  the  solution  cause 
severe  pain  in  some  cases.  Pain  during  injection  is  also 
caused  when  the  tissue  is  hypersensitive,  owing  to  patho- 
logical conditions,  such  as  in  gingivitis,  especially  if  the  solu- 
tion is  forced  into  an  acute  abscess  where  there  is  already 
pain  due  to  pressure  exerted  by  the  accumulated  pus. 

Toxic  effects  due  to  the  procaine  or  suprarenin  have 
already  been  discussed  at  length  (see  Pages  66  and  73).  For 
therapeutic  measures  see  Page  69. 

Failures 
Anatomical  conditions  may  prevent  success  in  local 
anesthesia.  In  the  chapter  dealing  with  the  anatomy  of 
the  maxillae  possible  anatomical  variations  have  already 
been  pointed  out.  Recognition  of  the  landmarks  is  of 
paramount  importance  and  anatomical  difficulties  have  to  be 
considered  when  selecting  the  technique  for  the  individual 
case.  The  anatomical  relations  and  structures  involved 
should  always  be  clearly  in  the  mind  of  the  operator. 

159 


i6o  ORAL  ANESTHESIA 

Faulty  Instruments  and  Technique.  Proper  selection 
of  needles  and  careful  technique  is  of  importance.  In  the 
infiltration  method,  the  most  frequent  causes  for  non-anes- 
thesia are  failure  to  reach  the  part  opposite  the  apex  of 
the  root,  which  may  be  due  to  too  short  a  needle,  from  not 
inserting  it  deep  enough  or  from  loss  of  contact  with  the 
bone.  In  conduction  anesthesia,  it  is  still  more  essential  to 
follow  the  technique  exactly  so  as  to  inject  the  solution  into 
the  connective  tissue  surrounding  the  nerve  to  be  anes- 
thetized, and  as  close  to  the  nerve  as  possible.  If  the  injec- 
tion is  not  made  close  enough  to  a  nerve  trunk  so  that  the 
latter  is  freely  infiltrated,  partial  anesthesia  results.  The 
parts  supplied  by  the  peripheral  nerve  fibers  may  be  numb, 
but  the  centrally  located  fibers  may  not  have  been  affected 
by  the  drug.  For  example,  in  conduction  anesthesia  of  the 
inferior  alveolar  nerve,  the  lip  may  be  numb,  but  one  of  the 
molar  teeth  may  react  partially  to  painful  stimuli.  An- 
other injection  will  usually  remedy  the  trouble.  At  times 
the  non-anesthesia  is  due  to  not  waiting  sufficiently  long. 
It  takes  from  ten  to  twenty  minutes  for  the  entire  nerve  to 
become  affected.  Again  it  may  occur  that  the  needle  is 
inserted  in  a  wrong  direction;  especially  in  the  pterygo- 
mandibular injection  one  is  liable  to  enter  the  internal 
pterygoid  muscle.  The  result  is  failure  to  get  anesthesia, 
and  stiffness  in  the  jaw  for  several  days,  the  patient  often 
being  hardly  able  to  open  the  teeth.  This  is  due  to  a  mus- 
cular trismus  which  will  last  until  the  solution  is  absorbed, 
sometimes  several  days,  because  absorption  from  muscles 
is  slow. 

Deteriorated  Drugs.  Procaine  or  suprarenin  which  has 
been  decomposed  is  much  less  active  and  may  lose  its  ther- 
apeutic effect  entirely.  Deteriorated  procaine  can  be  rec- 
ognized by  a  yellow  brownish  color.  Suprarenin  turns 
pink  to  brownish  red.  A  fresh  active  solution  is  as  clear 
as  water. 


ILL  EFFECTS.   FAILURES,   ACCIDENTS  i6l 

Accidents 

Breaking  of  Needle.  The  breaking  of  a  needle  is  an 
accident  which  may  be  caused  from  sudden  unexpected 
movements  by  the  patient.  This,  however,  can  be  pre- 
vented almost  entirely  by  using  iridio-platinum  needles, 
which  can  be  bent  several  times  at  the  same  place  before 
breaking.     (See  also  chapter  dealing  with  instruments.) 

Entering  Blood  Vessels.  Arteries  are  thick-walled  and 
elastic  and  are  inclined  to  give  way.  They  are  therefore 
not  easily  punctured.  Smaller  blood  vessels  and  capillaries 
can  be  avoided  by  injecting  a  small  amount  while  pushing 
the  needle  into  the  tissue.  However,  if  the  vessels  run  along 
the  path  of  the  needle  and  especially  if  enclosed  in  a  narrow 
bony  canal,  such  as  the  infraorbital  canal,  it  is  very  much 
more  difficult  to  avoid  them  and  it  is  necessary  to  use  special 
precaution.  In  such  cases,  after  the  needle  is  inserted,  the 
piston  of  the  syringe  should  be  slowly  withdrawn.  If  the 
point  of  the  needle  is  in  a  vessel,  blood  will  be  sucked  into 
the  syringe. 

Local  Vasoconstriction.  The  author  has  had  a  number  of 
cases  where  marked  anemia  has  resulted  in  the  skin  of  the 
face  immediately  after  the  injection  was  made.  At  one  time, 
a  blanched  area  as  large  as  a  silver  dollar  appeared  under- 
neath the  eye,  and  at  another  time  one  side  of  the  nose  was 
included.  This  condition  is  due  to  the  constricting  action 
of  the  suprarenin  on  the  smooth  muscle  tissue  in  the  walls 
of  an  artery,  which  may  be  so  complete  as  to  prevent  circu- 
lation entirely.  The  patient  is  not  conscious  of  this  con- 
dition and  it  is  better  not  to  call  his  attention  to  it,  or 
at  least  not  until  the  operation  is  completed. 

Entering  Nerve  Trunks.  If  a  nerve  trunk  is  injected, 
no  harm  follows,  though  a  sudden  radiating  pain  is  felt  in 
the  parts  suj)i)lied.  Anesthesia  is  complete  almost  imme- 
diately. 

Should  nerve  fibers  be  torn  accidentally  during  injection. 


1 62  ORAL  ANESTHESIA 

temporary  anesthesia  of  the  parts  suppHed  persists  until 
the  fibers  regenerate. 

Anesthesia  of  Motor  Fibers.  Motor  fibers,  especially 
of  the  facial  nerve,  are  occasionally  infiltrated,  which  results 
in  temporary  muscular  disturbances  indicated  by  the  closing 
of  the  eyelid  or  drooping  of  a  part  of  the  upper  lip.  These 
conditions,  while  disfiguring,  disappear  as  soon  as  the  effect 
of  the  anesthetic  wears  off.  Reassure  the  patient  by  ex- 
plaining that  the  parts  will  return  to  normal  in  a  very  short 
time. 

Psychic  Shock.  Psychological  effects  on  the  human 
organism  have  only  recently  received  proper  consideration. 
Research  on  this  subject  by  Cannon  and  Crile  furnishes 
food  for  deep  thought  and  offers  explanations  for  certain 
clinical  observations,  which  heretofore  have  been  laid  to 
the  toxicity  of  a  drug  or  the  idiosyncrasy  of  a  patient. 

Of  the  various  emotions,  fear  is  perhaps  the  strongest 
and  deepest  rooted.  It  is  closely  associated,  however,  with 
pain  and  anger,  all  of  which  arouse  in  the  body  peculiar 
instinctive  reactions.  Crile  has  given  expression  to  the 
view  that  on  a  principle  of  " phylogenetic  association" 
these  emotions,  born  of  innumerable  injuries  in  the  course 
of  evolution,  have  developed  into  portentous  foreshadowings 
of  possible  injury,  and  have  become,  therefore,  capable  of 
putting  into  action  all  offensive  and  defensive  activities 
that  favor  the  survival  of  the  organism.  These  responses 
are  automatic  and  not  willed  movements,  and  the  ability 
to  suppress  them,  more  or  less,  is  gained  by  racial  and  in- 
dividual training.  This  virtue  of  heroically  submitting  to 
physical  punishment  and  suffering  is,  however,  not  a 
mark  of  high  civilization,  as  is  illustrated  by  the  stoic  Amer- 
ican Indian  of  the  days  gone  by  and  the  spoiled  child  of 
our  own  race. 

Flight  and  fight  express  the  most  characteristic  inherited 
impulses  which  may  be  produced  either  singly  or  combined 


ILL   EFFECTS,   FAILURES,   ACCIDENTS  163 

in  man.  The  first  is  manifested  by  the  attempt  or  inten- 
tion to  withdraw  from  painful  and  dangerous  contact,  while 
the  other  causes  modifications  of  the  action  seen  in  animals 
at  bay  or  in  attack.  ]\Iuscular  tension,  defensive  movements 
with  the  arms,  the  set  jaw,  clenched  fists,  and  dilated  nos- 
trils are  often  observable  in  certain  patients.  The  effect 
of  these  energies,  generated  but  not  actually  transformed 
into  activity,  on  the  body  mechanism,  Crile  compares  with 
the  detrimental  action  of  a  motor  running  at  full  speed  in 
an  automobile  which  is  kept  stationary.  It  expresses  itself 
in  trembling,  sweating,  blanching,  rapid  respiration  and 
palpitation.  The  result  often  is  exhaustion  and  causes, 
according  to  Crile,  a  low  brain  threshold.  Therefore,  in 
patients  obsessed  by  fear,  all  stimuli  —  both  physical  and 
psychical  —  are   augmented. 

On  this  basis  must  be  explained  the  extreme  prostrating 
effects  produced  in  many  people  by  the  sound  of  instruments, 
traumatic  injury,  the  sight  of  blood,  and  often  even  merely 
the  thought  of  an  operation.  It  should  also  be  remem- 
bered that  some  patients  associate  local  anesthesia  with 
cocain  and  fear  its  toxic  effects;  and  unfortunately  pros- 
pective patients  have  frequently  been  well  informed  by 
their  friends  of  all  the  accidents,  toxic  effects,  and  post- 
operative sequelae  that  have  come  to  their  knowledge. 

Fear,  therefore,  is  an  important  factor  and  cannot  be 
neglected,  as  it  is  frequently  the  cause  of  untoward  effects, 
developed  by  some  patients  before  or  after  the  anesthetic 
solution  is  injected.  The  pain  caused  by  the  initial  puncture 
should  also  be  considered  in  this  connection.  Several  years 
ago  the  writer  made  clinical  demonstrations,  selecting  hos- 
pital patients  of  various  temperaments.  It  was  observed  that 
in  nervous,  sensitive  patients  the  pulse  rate  markedly  in- 
creased when  the  needle  was  inserted  and  before  any  solu- 
tion was  injected.  In  the  phlegmatic  type,  the  patient  did 
not  complain  of  i)ain  when  the  needle  was  inserted,  and  the 


1 64  ORAL  ANESTHESIA 

pulse  rate  remained  almost  the  same.  Psychic  shock  is 
also  more  likely  to  occur  in  individuals  who  have  been  suf- 
fering from  pain  and  insomnia  and  whose  general  resistance 
is  lowered  by  various  diseases,  such  as  anemia,  hysteria, 
toxemia,  and  infection.  The  following  will  serve  as  an 
illustration  in  which  debilitating  factors  combined  with 
fear  were  the  cause  of  an  accident  which  would  have  been 
laid  to  the  toxic  effects  of  the  anesthetic,  had  it  occurred 
after  the  injection.  The  incident  happened  on  the  occa- 
sion of  a  demonstration  given  by  the  author  before  the  State 
Society  of  Massachusetts  in  May,  1913.  The  patient,  a 
mail  carrier,  about  thirty  to  thirty-five  years  of  age,  was 
seated  in  the  chair  in  front  of  the  audience.  He  had  been 
suffering  pain  for  several  days  and  was  weakened  from  loss 
of  sleep.  While  explaining  the  technique  of  the  injection 
suitable  for  the  case,  the  patient  suddenly  collapsed.  No 
injection  had  been  made. 

It  is  evident,  therefore,  that  to  operate  successfully 
under  local  anesthesia  confidence  must  be  inspired  by  a 
convincing  attitude  and  a  certainty  of  success  which  will 
dispel  lack  of  faith,  obviate  fear,  and  prevent  those  con- 
ditions caused  by  the  emotions. 

Syncope.  The  loss  of  consciousness  due  to  reflex  in- 
hibition of  the  cardiac  and  respiratory  centers  starts  with 
paleness,  nausea,  cold  sweat,  and  dizziness.  It  comes  on 
with  dilation  of  the  pupils  and  muscular  relaxation  and  is 
accompanied  by  rapid,  small  and  regular  pulse,  slow  and 
shallow  respiration.  It  is  caused  by  emotions,  such  as  fear, 
especially  if  the  air  is  hot  and  close.  Anemic  persons  are 
very  susceptible,  and  a  slight  amount  of  pain  or  the  sight  of 
blood  may  cause  syncope.  The  condition  is  as  a  rule  not 
serious  and  disappears  soon  under  the  proper  therapeutic 
measures.  Place  the  patient  with  the  head  at  a  lower  level 
than  the  rest  of  the  body.  Children  may  literally  be  placed 
on  their  heads.     For  adults,  the  recumbent  position  is  com- 


ILL  EFFECTS,   FAILURES,   ACCIDENTS  165 

mendable,  or  the  head  may  be  lowered  between  the  knees, 
if  the  patient  is  sitting.  The  last  two  methods  will  pre- 
vent the  entire  loss  of  consciousness,  when  resorted  to  as 
soon  as  the  first  symptoms  appear,  and  in  anemic  patients 
a  recumbent  position  should  be  selected  from  the  first. 
Aromatic  spirits  of  ammonia  by  inhalation  is  one  of  the 
quickest  acting  stimulants.  If  the  patient  has  not  lost 
consciousness,  it  may  also  be  administered  by  the  mouth. 
The  dose  should  be  given  in  a  very  small  amount  of  water. 
Its  action,  due  to  irritation  of  the  mucous  membrane,  is 
better  and  quicker  in  concentrated  form.  Camphorated 
Validol,  already  recommended,  is  an  excellent  preparation 
and  is  best  administered  on  a  piece  of  sugar.  Use  5  to  10 
drops.  In  severe  cases,  strychnia,  1/60  or  1/30  of  a  grain 
hypodermically,  is  one  of  the  most  reliable  remedies  and 
should  always  be  kept  on  hand  in  Greeley  Units  (see  page 
69).  Black  coffee  should  be  given  the  patient  before  leaving 
the  office.  It  is  a  splendid  stimulant,  on  account  of  its 
lasting  action. 

Syncope  should  be  distinguished  from  collapse  due  to 
toxic  action  of  the  anesthetic  solution,  and  treated  as  de- 
scribed under  separate  head  (see  page  69). 

Postanesthetic  and  Postoperative  Effects 
Tissue  Lesions.  If  the  anesthetic  is  properly  prepared 
from  fresh  drugs  and  isotonic  sterile  Ringer  solution  with- 
out harmful  and  unnecessary  admixtures,  there  is  no  danger 
of  harmful  effects  on  the  tissues.  If  pathological  conditions 
occur  following  local  anesthesia,  they  may  either  be  traced 
to  infection  from  non-sterile  solutions,  or  instruments,  to 
infection  of  the  wound  made  by  the  puncture  of  the  needle 
during  or  after  the  operation,  or  to  too  high  a  percentage  of 
suprarenin.  Complete  anemia  is  not  desirable  except  in 
very  rare  instances.  Arrest  of  circulation  increases  the 
possibiHty  of  infection.     Bleeding  is  both   a  cleansing  and 


1 66  ORAL  ANESTHESIA 

protective  reaction.  Its  prolonged  inhibition  or  entire  ab- 
sence retards  normal  repair  and  gives  bacterial  invasion  a 
chance  for  unrestricted  development.  Injecting  into  sup- 
purative lesions  should  also  be  avoided  on  account  of  the 
danger  of  spreading  the  infection  or  carrying  organisms 
into  deeper,  healthy  structures.  Conduction  anesthesia 
eliminates  dangers  from  this  source  and  also  enables  the 
operator  to  distinguish  between  conditions  caused  by  oper- 
ative procedures  from  those  that  might  be  blamed  on  the 
injection.  The  author  has  inquired  into  the  history  of 
many  cases  of  alleged  tissue  lesions  or  after-pain,  and  found 
that  frequently  opponents  of  local  anesthesia  encourage 
the  patient,  without  investigating,  in  the  belief  that  such 
conditions,  which  may  clearly  be  due  to  operative  proce- 
dures, are  caused  by  the  procaine.  Worse  still,  I  have  found 
that  there  are  dentists  who  blame  the  drug  if  their  own  cases 
happen  to  be  followed  by  complications,  from  fear  that  the 
patient  may  find  fault  with  their  operative  ability  or  surgical 
skill. 

The  question  whether  the  dental  pulp  may  be  perma- 
nently injured  if  a  tooth  is  anesthetized  has  been  raised. 
It  is  the  writer's  opinion  that  no  harm  can  be  done  if  con- 
duction anesthesia  is  used,  and  with  the  infiltration  method 
the  only  danger  is  through  infection.  More  likely  causes 
of  inflammation  of  the  pulp  after  local  anesthesia  may 
be  found  in  the  operative  procedure,  especially  on  account 
of  the  tendency  to  generate  too  much  heat. 

Edema  is  due  to  an  accumulation  of  serum  in  and  be- 
tween the  cells  of  the  tissue.  The  swelling  may  be  due  to 
infection  or  the  condition  may  be  caused  by  toxic  or  irri- 
tating effects  upon  the  protoplasm  from  deteriorated  drugs, 
antiseptics  or  other  unnecessary  additions  to  the  anesthetic 
solutions;  by  solutions  which  are  not  isotonic;  by  trauma- 
tism, caused  by  inserting  the  needle  several  times  in  the 
same    part,    correcting    the    direction;    by    injecting    into 


ILL  EFFECTS,   FAILURES,   ACCIDENTS  167 

muscles,  from  which  absorption  is  sluggish,  sometimes  caus- 
ing for  several  days  stiffness  and  interference  with  normal 
action.  If  the  internal  pterygoid  muscle  is  infiltrated,  it  may 
result  in  trismus,  which  interferes  considerably  with  the  mo- 
tions of  the  jaw,  and  frequently  causes  swelling  of  the  throat. 
Edema,  not  due  to  infection,  will  disappear  without 
treatment.  Cold  applications  will  give  comfort  to  the 
patient  and  massage  and  exercise  will  promote  absorption 
from  muscles. 

J     After-pain.     The  question  of  pain  following  an  operation 
After  the  effects  of  a  general  or  local  anesthetic  have  worn 
/off   is   one   of   greatest   importance.      The   custom   of   dis- 
I  missing    the    patient,   after   having  performed   a  perfectly 
''  painless    operation,    leaving    him    in   ignorance   as   to    the 
possibility  of  postoperative  pain  is  to  be  deplored.     By  a 
little  forethought,  it  is  not  only  possible  to  almost  entirely 
eliminate   physical    suffering    from   postoperative    sequelae, 
but  also  to  preserve  the  mental  equilibrium  of  the  patient, 
and  more  than  that,  to  prevent  important  general  physio- 
logical disturbances.     Cannon  has  shown  that  pain  causes 
digestive   disturbances   by   arresting  the  flow  of  the  gastric 
juices  and  inhibiting  the  normal  contractions  of  the  stomach 
and  intestines. 

The  degree  of  suffering  varies.  Hertzler,  in  his  article 
on  "After-pain  in  its  Relation  to  General  and  Local  Anes- 
thesia," writes:  "  The  interpretation  of  pain  by  the  indi- 
vidual patient  is  the  deciding  factor,  and  consequently 
the  testimony  is  subject  to  endless  variation.  The  patient's 
own  testimony  varies.  He  may  complain  of  pain  a  few 
hours  after  the  operation,  while  after  a  week  he  may  no 
longer  recall  his  experience  as  painful,  but  willingly  attrib- 
utes -his  discomfort  to  the  apprehension  of  possibilities  of 
wound  complication."  The  susceptibility  of  the  individual 
is  an  important  factor.  It  is  influenced  by  the  race,  tem- 
perament,  mental   attitude,  and   state   of  health. 


1 68  ORAL  ANESTHESIA 

After  these  general  remarks  on  pain  occurring  after  op- 
erations, it  is  necessary  for  our  special  purpose  to  distinguish 
between  after-pain  due  to  local  anesthesia  and  postoperative 
sequelae  due  to  the  operative  procedure  itself.  The  latter 
are  usually  due  to  the  trauma  of  the  operation.  Simple 
trauma  does  not  cause  a  great  deal  of  pain,  however,  unless 
complicated  by  tissue  destruction  due  to  thermal  influences, 
such  as  heat  generated  by  a  bur,  causing  pulpitis,  or  by 
lasting  mechanical  irritation,  such  as  is  often  produced  by 
tight  dressings  and  more  frequently  by  sharp  pieces  of 
bone  sticking  into  the  membrane  covering  it,  or  foreign 
bodies,  parts  of  fillings,  or  fractured  particles  of  enamel, 
and  detached  pieces  of  bone  which  may  remain  in  the  wound. 
Infection  also  plays  an  important  part.  Bacterial  influences 
and  food  cannot  be  entirely  excluded  from  wounds  in  the 
oral  cavity,  but  fortunately,  a  blood  clot  generally  closes 
the  wound  and  furnishes  sufficient  protection.  If,  on  the 
other  hand,  the  deeper  structures  remain  uncovered  or  if 
the  clot  fails  to  organize  or  breaks  down,  postoperative 
complaints  are  sure  to  ensue.  In  the  writer's  opinion, 
after-pain  is  in  most  cases  due  to  the  operation  proper,  and 
not  to  the  anesthetic,  which  can  be  demonstrated  in  con- 
duction anesthesia,  where  the  injection  is  made  in  a  place 
remote  from  the  field  of  operation,  or  in  anesthesia  for 
operations  on  hard  tooth  substances,  performed  with  proper 
care  so  that  the  pulp  has  not  been  injured. 

Comparison  of  the  amount  of  postoperative  pain  after 
general  or  local  anesthesia  is  difficult,  owing  to  the  different 
susceptibility  of  various  individuals,  as  well  as  the  same 
patient  at  different  times,  and  in  no  less  a  degree  to  the 
variations  in  the  clinical,  pathological  and  surgical  aspects 
of  one  type  of  an  operation.  Moreover,  the  general  custom 
of  using  morphia  previous  to  administering  ether  will  some- 
times give  the  patient  many  hours'  comfort  during  the  time 
when  after-pain  would  be  most  severe.     Of  course,  prean- 


ILL  EFFECTS,   FAILURES,   ACCIDENTS  169 

esthetic  medication  can  be  employed  with  local  anesthesia. 
Then  again,  the  condition  of  the  patient  after  ether  is  quite 
different  from  the  condition  after  local  anesthesia,  due  to 
disturbed  sensibility  and  nausea,  which  at  times  is  so  bad 
that  after-pain  is  hardly  noticed  at  the  time. 

Postanesthetic  pain  after  local  anesthesia  may  actually 
occur,  however.  It  is  usually  avoidable  and  generally  the 
fault  of  the  anesthetist.  In  the  following,  some  causes 
which  may  produce  postanesthetic  pain  are  enumerated: 
deteriorated  drugs  through  their  toxic  action  on  the  tissue 
cells,  as  well  as  antiseptics,  if  strong  enough  to  destroy  bac- 
teria; the  use  of  too  hot  or  too  cold  a  solution;  injecting 
too  fast,  causing  laceration  of  the  tissue;  the  use  of  a  blunt 
needle  or  unnecessary  injury  when  inserting  it;  changing  the 
direction  of  the  needle  several  times;  injecting  air  into  the 
tissue;  infection  from  non-sterile  needles  and  solutions; 
infection  spread  by  injecting  into  parts  where  pus  has  ac- 
cumulated, and  one  more  important  condition  which  has 
been  brought  to  the  attention  of  the  profession  by  Dr.  Lewis 
of  Lake  Forest,  Illinois,  in  an  excellent  article  published 
in  the  May  Cosmos,  1919.  He  claims  that  after-pain  may 
frequently  be  due  to  the  chilling  of  the  anesthetized  part. 
Local  circulation  is  retarded,  due  to  the  constricting  action 
of  the  suprarenin,  preventing  the  area  from  receiving  the 
normal  proportion  of  warmth  from  the  blood.  On  account 
of  the  anesthesia,  the  patient  is  unable  to  feel  the  cold. 
This,  he  believes,  brings  about  in  some  persons  considerable 
discomfort  as  the  effect  of  the  anesthetic  departs,  and  it 
is  his  firm  conviction  that  pain  is  almost  invariably  suffered 
by  nearly  all  persons  in  proportion  as  the  temperature  is 
lowered  during  the  period  of  anesthesia.  Patients  there- 
fore should  be  advised  to  keep  the  face  protected,  and  com- 
fortably warm,  until  the  effect  of  the  anesthetic  has  worn 
off,  not  c)nly  in  winter,  but  also  on  cold  and  windy  summer 
days,  or  if  the  ])atient  drives  home  in  an  open  automobile. 


170  ORAL  ANESTHESIA 

It  is  evident  that  postanesthetic  pain  can  be  avoided 
with  proper  care  and  technique,  and  pain  occurring  from 
the  operation  or  condition  of  the  wound  should,  if  anticipated 
by  the  operator,  receive  proper  consideration.  The  in- 
teUigent  patient  may  be  told  what  is  to  be  expected  and 
instructed  in  palliative  measures.  A  prescription  should 
be  given  according  to  the  amount  of  pain  expected.  The 
following  have  been  found  excellent  by  the  writer:  Phen- 
acetin  and  Aspirin  gr.  v  of  each,  taken  when  pain  comes 
on  and  repeated  after  one  hour  if  necessary.  In  more  severe 
cases: 

Phenacetin  Gr.  xxiv 

Sodii  bicarb.  Gr.  xl 

Codein.  sulph.  Gr.  ii 

Caffein.  cit.  Gr.  viii 

Fiat  capsulae  No.  viii 
Sig.     Take  for  severe  pain  and  repeat  after  three  hours 
if  not  relieved. 

For  prompt  relief  give  1/8  or  1/4  grain  of  morphia 
hypodermically. 

To  avoid  infection  of  the  wound  made  by  the  puncture  of 
the  needle  apply  tannic  acid  and  glycerin  equal  parts  imme- 
diately after  the  injection.  This  acts  as  an  astringent, 
contracting  the  wound  margins,  as  well  as  a  protective  agent. 
The  same  may  be  used  on  wounds. 

Prolonged  Anesthesia.  Cases  of  prolonged  anesthesia 
have  been  reported  to  last  for  several  days  or  weeks.  These 
may  be  traced  to  injury  of  a  nerve  during  the  operation, 
as  in  the  case  of  the  lower  jaw  when  the  tooth  sockets  come 
in  contact  with  the  mandibular  canal.  In  impacted  wisdom 
teeth,  there  is  special  danger  of  injuring  the  inferior  alveolar 
nerve.  A  fractured  piece  of  bone,  when  misplaced,  may  cause 
pressure  on  the  nerve.  Accidental  injection  of  alcohol  may 
also  be  mentioned  here.  The  syringe,  after  being  taken  from 
the  jar,  should  be  carefully  rinsed,  as  described  on  page  83. 


PART   VIII 

PRACTICAL   APPLICATION    OF   LOCAL   ANES- 
THESIA  IN   DENTISTRY   AND    ORAL    SURGERY 

AFTER  the  student  has  become  familiar  with  the  va- 
rious methods  of  local  anesthesia,  he  needs  as  a  rule  a 
little  help  in  order  to  put  into  practice  his  newly  acquired 
knowledge.  Not  only  is  it  of  importance  that  he  know 
what  method  is  best  suited  for  a  practical  case,  but  he  must 
become  accustomed  to  operating  under  the  new  conditions. 
Pain,  which  in  many  operations  the  dentist  is  accustomed  to 
rely  upon  as  a  signal  before  serious  damage  is  done  to  healthy 
tissue,  and  which  he  has  become  used  to  having  as  a 
guide  for  the  extent  of  his  operation,  is  entirely  abolished. 
Therefore,  it  is  necessary  to  make  a  more  extensive  and 
careful  investigation  of  the  pathological  condition  and 
use  more  judgment  and  precaution  when  rapid  cutting  in- 
struments are  applied. 

Two  good  rules  for  selecting  the  method  of  anesthesia 

are: 

1.  Use  always  the  simplest  and  surest  method. 

2.  Avoid  injecting  into  pathological  tissue. 
Cavity   Preparation.     For   all   purely   dental   operations 

involving  only   the  hard  structures  of  the    tooth  and  the 

dental  pulp,  we  need  only  to  anesthetize  the  dentinal  nerve 

supplying  the  tooth  in  question.     The  accessory  injections 

for  the  investing  structure  are  not  needed,   except  if  the 

gum  has  to  be  retracted  with  a  high  cervical  clamp  or  in  other 

cases   involving   the    soft    tissue.     The   conductive   method 

171 


172  ORAL  ANESTHESIA 

will  be  found  of  special  advantage  if  cavities  are  to  be  pre- 
pared in  several  adjoining  teeth.  It  is  advisable  to  prepare 
all  cavities  in  the  teeth  to  be  anesthetized  at  one  time  re- 
gardless of  whether  they  can  be  filled  the  same  day.  When 
preparing  a  cavity  for  a  filling  under  anesthesia,  care  must 
be  taken  to  avoid  heating  the  tooth.  Thermal  shocks, 
though  not  felt  by  the  patient,  may  burn  the  delicate  pulp 
tissue,  cause  inflammation  and  subsequently  death  of  the 
pulp.  It  should  be  remembered  that  the  pulp  chamber 
varies  in  size  not  only  with  the  age  of  the  patient,  but  also 
in  persons  of  the  same  age.  If,  therefore,  the  cavity  is 
extensive,  it  is  of  great  value  to  ascertain  the  outline  of 
the  pulp  chamber  by  means  of  a  Roentgen  film,  and  after  the 
operation  is  finished,  the  dentinal  tubules  should  be  sealed 
by  applying  carbolic  ether  rosin  to  the  cavity,  both  to 
prevent  irritation  and  pain  when  the  anesthetic  has  worn 
off,  as  well  as  on  account  of  the  danger  of  bacterial  inva- 
sion which  later  might  cause  infection  of  the  pulp. 

Crown  and  Bridge  Work.  In  crown  and  bridge  work  the 
most  radical  dental  operations  are  performed.  Not  only  is 
it  necessary  to  remove  more  tooth  substance  than  in  any 
other  dental  operation,  but  the  grinding  seems  almost  un- 
bearable to  many  patients  and  this  in  turn  frequently  pre- 
vents the  dentist  from  performing  his  work  with  exactness. 
It  is  therefore  evident  that  local  anesthesia  will  not  only 
prevent  suffering,  but  gives  an  opportunity  for  better  work, 
and  therefore  is  of  double  benefit  to  the  patient.  It  will 
also  do  away  with  one  of  the  reasons  why  teeth  have  been 
devitalized  in  the  past,  some  operators  finding  it  necessary 
to  eliminate  pain  by  removing  the  dental  pulp  in  order  to 
be  able  to  get  satisfactory  results.  The  abutments,  as  well 
as  the  soft  tissue,  generally  need  to  be  anesthetized,  the  latter 
to  eliminate  pain  caused  by  the  preparation  of  the  neck 
of  the  tooth  and  the  fitting  of  crowns  and  bands.  Here 
again   the   exposed  dentine   should  be   protected   after   the 


PRACTICAL   APPLICATION   OF   LOCAL   ANESTHESIA      173 

operation  is  completed.  It  is  the  writer's  firm  belief  that 
the  principal  cause  of  pulp  disease  after  crowning  a  vital 
tooth  is  from  infection,  through  bacteria  which  have  found 
entrance  into  the  dentinal  canals  sectioned  in  close  proximity 
to  the  pulp  during  the  time  which  elapsed  between  tooth 
preparation  and  cementing  the  crown  into  place.  The  pain- 
less fitting  of  crowns  and  bands  can  be  accomplished  by  sur- 
face anesthesia,  as  described  on  page  89. 

Pulp  Extirpation.  The  importance  of  saving  the  dental 
pulp  is  becoming  more  evident  every  day.  Preventive  den- 
tistry does  a  great  deal  toward  preserving  this  important 
organ,  and  the  serious  conditions  resulting  from  devitalized 
teeth,  case  reports  of  which  are  to  be  found  in  every  edition 
of  any  dental  journal,  clearly  point  out  that  the  removal 
of  healthy  pulps  is  a  poor  practice  except  in  occasional  in- 
stances. The  treatment  of  pathological  pulps  should  only 
be  undertaken  after  careful  Roentgen  examination.  It  is 
important  to  know  the  condition  of  the  periapical  tissues, 
the  size  and  shape  of  the  root  canal,  and  whether  there  are 
obstructions  to  proper  treatment,  such  as  pulp  stones  or 
other  calcifications.  Infiltration  or  conduction  anesthesia 
may  be  used.  If  a  slight  amount  of  sensation  remains,  and 
this  occasionally  happens  if  the  pterygomandibular  injection 
is  employed  to  anesthetize  the  lower  molars,  complete  anes- 
thesia is  easily  obtained  by  the  use  of  pressure  anesthesia, 
which  is  a  supplementary  method.  Local  anesthesia  is 
especially  helpful  in  all  cases  where  other  methods  cannot 
be  applied  or  have  proven  a  failure,  especially  if  due  to  de- 
posits, pulp  stones  in  the  root  canals,  and  in  teeth  with 
hypertrophied  pulps  and  where  sensitive  nerve  tissue  has 
been  left  in  the  apical  part  of  the  root  canal.  When  ex- 
tirpating a  pulp  under  local  anesthesia,  it  is  important  to 
realize  that  the  periapical  tissues  are  also  anesthetized  and 
proper  care  must  be  exercised  so  as  not  to  injure  or  infect  the 
peridental    membrane.     The    length   of    the  root  canal  can 


174  ORAL  ANESTHESIA 

be  estimated  by  means  of  a  Roentgenogram  and  another 
Roentgen  film  should  be  taken  with  a  broach  inserted  to  make 
sure  that  the  pulp  tissue  has  been  removed  to  the  very  apex 
of  the  tooth.  It  is  generally  better  to  fill  the  canal  at  a 
subsequent  sitting,  as  the  patient  is  not  able  to  cooperate 
and  we  have  no  way  of  telling  when  the  filling  has  penetrated 
the  apex. 

If  the  infection  has  gone  beyond  the  apical  foramen, 
causing  acute  periodontitis  or  acute  abscess,  the  conduction 
method  is  indicated,  so  as  not  to  inject  into  tissue  more  or 
less  infiltrated  with  pus. 

Treatment  of  Pyorrhea  Alveolaris.  The  conduction 
methods  are  of  great  help  in  the  treatment  of  pyorrhea, 
especially  if  cauterizing  of  hypertrophied  tissue  is  necessary. 
Some  operators  object  to  the  painless  method,  claiming  that 
it  increases  the  chance  of  lacerating  healthy  tissue.  How- 
ever, it  is  greatly  appreciated  by  the  sensitive  patient,  es- 
pecially in  cases  where  a  great  deal  of  instrumentation  is 
required. 

Diagnosis  of  Trifacial  Neuralgia.  It  is  often  difficult  to 
locate  the  cause  of  minor  neuralgia  or  to  determine  which 
division  of  the  trigeminal  nerve  is  affected.  Many  times 
there  are  several  conditions  found  by  means  of  Roentgen 
diagnosis,  any  of  which  might  be  the  cause  of  the  trouble. 
It  is  possible  by  means  of  local  anesthesia  to  confirm  or  dis- 
prove a  diagnosis  by  anesthetizing  the  suspected  nerve 
branch  or  tooth. 

Alcohol  Injections  for  Major  Neuralgia.  The  various 
methods  of  conduction  anesthesia,  especially  the  extraoral 
ones,  are  used  for  injecting  alcohol  in  the  treatment  of 
neuralgia  majores  or  tic  douloureux.  These  injections 
cause  prolonged  anesthesia,  lasting  generally  about  six 
months  or  longer  and  then  they  have  to  be  repeated.  Al- 
cohol is  used  in  various  strengths,  or  the  following  formula, 
recommended  by  Patrick: 


PRACTICAL   APPLICATION  OF  LOCAL  ANESTHESIA       175 

Novocain  2  per  cent 

Chloroform  5  per  cent 

Alcohol  70  per  cent 

Ringer  solution  23  per  cent 

If  the  injection  is  made  into  the  deep  orbit,  he  recom- 
mends reducing  the  quantity  of  chloroform  to  2  per  cent. 
The  normal  healthy  patient  should  receive  ^  grain  of  codein 
or  1/  150  grain  of  scopolamin,  and  1/6  grain  of  morphia  about 
thirty  minutes  before  the  injection. 

Oral  Surgery.  The  advantages  of  local  anesthesia  for 
extraction  of  teeth  and  other  surgical  operations  in  and 
about  the  mouth  have  already  been  spoken  of  elsewhere 
at  length.  The  operator  who  has  had  experience  with  both 
gas  and  oxygen  anesthesia  and  the  local  methods  will  have  no 
difficulty  in  choosing,  and  most  patients  who  have  had 
experience  with  the  two  ways  will  be  found  ardent  advo- 
cators of  local  anesthesia. 

Extraction  of  Teeth.  In  exodontia  local  anesthesia  is 
entirely  successful.  With  the  old  method  of  injecting  into 
the  gum  producing  a  gingival  velum,  the  operation  was 
often  painful.  The  methods  described  in  this  book  make 
it  possible  to  fully  control  pain  by  anesthetizing  not  only 
the  superficial  structures,  but  also  the  periosteum,  bone, 
peridental  membrane,  and  the  tooth  itself;  and  it  lasts 
sufficiently  long,  no  matter  how  difficult  and  tedious  the 
case  may  be,  giving  the  operator  opportunity  to  resect  ir- 
regular, sharp,  bony  protuberances,  which  hastens  healing 
and  allows  early  restoration  by  artificial  appliances. 

Operations  on  the  Jaws.  Any  standard  operation  may 
be  performed  on  the  jaws.  Local  anesthesia  is  used  by  the 
writer  continuously  for  apicoectomy,  the  removal  of  im- 
pacted teeth,  cysts,  tumors  of  the  jaws,  and  the  setting  of 
difficult  fractures. 

Operations  on  the  Maxillary  Sinuses.  Conduction  an- 
esthesia   may    })e    used,    es])ecia]ly    the    sphenomaxillary    or 


176  ORAL  ANESTHESIA 

extraoral  maxillary  method.  It  is  often  sufficient,  however, 
to  inject  the  anterior  wall  with  the  submucous  method  for 
making  an  opening  through  the  canine  fossa,  such  as  would 
be  necessary  to  remove  a  root  or  tooth  which  may  have 
been  forced  into  this  cavity. 

Resections  of  the  Jaws.  Both  the  upper  and  lower 
jaws  may  be  resected  with  local  anesthesia.  The  extraoral 
methods  are  used  for  such  extensive  operations.  In  the 
upper  jaw,  the  entire  second  division,  including  the  spheno- 
palatine ganglion  and,  in  the  lower,  the  entire  third  division, 
should  be  anesthetized.  If  incisions  are  made  in  the  skin, 
these  should  be  taken  care  of  separately  on  account  of  the 
many  interlacing  branches  and  the  multiplicity  of  their 
origin.  The  elimination  of  the  anesthetist  and  his  ap- 
pliances, better  control  of  hemorrhage,  and  the  absence 
of  contamination  of  the  wound  by  vomiting  are  advantages. 

In  all  operations  of  more  extensive  character,  preanes- 
thetic medication  is  absolutely  essential  to  dull  the  pa- 
tient's keenness  and  apprehension  sufficiently  to  eliminate 
any  complications  from  emotional  and  psychic  activities. 


INDEX 


A 

Accidents,  i6i 
Adrenalin,  70 
After-pain,  166,  167 
Alcohol,  injected  accidentally,  1 70 
Alcohol,  injected  in  trifacial  neuralgia,  1 74 
Alypin,  63 

Ampules  with  Procaine-suprarenin  solu- 
tion, 80 
Anatomy,   consideration    for    infiltration 

anesthesia,  93 
Anatomy,  consideration  in 

buccinator  injection,  126 

causing  failures,  159 

extraoral  infraorbital  injection,  157 

maxillary  injection,  152 

palatine  injection,  139 

pterygomandibular  injection,  113 

sphenomaxillary  injection,  126 

zygomatic  injection,  132 
Anemia, 

general,  164 

local,  74,  165 
Anesthesia, 

absorption,  89 

conduction, 
extraoral,  144 
intraoral,  no,  113 

general,  18 

infiltration,  93 

local,  technique,  89 

local  vs.  general,  18,  168,  175,  176 

nasal,  90 

of  adjoining  teeth,  109 

of  a  number  of  teeth,  109 

of  individual  teeth,  98,104 

of  motor  nerves,  162 

of  pulp,  90 

prolonged,  170 

selection  of,  18 

surface,  89 
Anesthesin,  63 


Anger,  162 
Anoci-association,  17 
Application, 

nasal,  91 

practical  of  local  anesthesia,  171 

to  exposed  pulps,  91 
Apothesine,  63,  64 
Associations,  phylogenetic,  16,  162 
Author's  method  of  preparing  the  solu- 
tion, 81 

B 

Bleeding,  cleansing,  165 
Blood  pressure  and  suprarenin,  74 
Blood  vessel,  entering,  161 
Bottle  for  Ringer  solution,  59 
Bromurol,  Knoll,  86 
Buccinator  injection,  126 


Camphor,  in  oil,  70 
Canal,  palatine,  27 
Cavity,  nasal,  29 

preparations,  171 
Cocain,  discovery,  62 

contraindications,  63  '' 

habit-forming,  63 
Coffee,  as  stimulant,  71 
Cold,  exposure  to  after  local  anesthesia, 

169 
Conduction  anesthesia,  no 
Conduction  anesthesia,  advantages,   ni, 
166 

extraoral,  144 

intraoral,  113 
Confidence  of  operator,  85 

of  patient,  17 
Contents,  n,  12,  13 
C'rown  and  bridge  work,  172 
Cups  to  j)repare  solution,  57 
Cysts,  17s 
177 


178 


INDEX 


D 

Diagnosis  of  trifacial  neuralgia,  174 

Distilled  water,  77 

Distilled  water,  Femel  apparatus,  76 

Kells  still,  78 
Dizziness,  164 
Drugs,  deteriorated,  160 

for  absorption  anesthesia,  90 


E 
Edema,  166 
Effects,  postanesthetic,  165 

postoperative,  165 

prostrating,  163 

toxic,  159 

combatting  of,  69 
Einhorn,  64 
Eminence,  canine,  lower  jaw,  30 

canine,  upper  jaw,  19 
Endermic  injection,  98 
Engstadt's  method  in  cocain  poisoning, 

70 
Ether  in  cocain  poisoning,  70 
Eucaine,  63 
Extraction  of  teeth,'  175 


Failures  and  ill  effects,  159 

anatomical  conditions,   159 

deteriorated  drugs,  160 

faulty  instruments,  160 

faulty  technique,  160 

in   extraoral  pterygomandibular   in- 
jection, 151 

in  pterygomandibular  injection,  122 

in  sphenomaxillary  injection,  131 

in  zygomatic  injection,  134 

respiratory,  69  , 

Fainting,  69 
Fear,  15,  162,  164 
Femel  apparatus,  79 
Foramen,  incisive,  26 

infraorbital,  21 

mandibular,  34 

mental,  31 

palatine,  27 

posterior  superior  alveolar,  23 
Foreign  body,  in  maxillary  sinus,  176 


168,  17s, 


Fossa,  canine,  20,  21 
incisive,  20 
mental,  30 
semilunar,  39 
zygomatic,  22 

Fractured  jaws,  175 


Ganglion,  otic,  51 

sphenopalatine,  44 
submaxillary,  52 

General  anesthesia  vs.  local,  i 
176 

Greeley's  units,  69 

H 

Habits,  phylogenetic,  16,  162 

Halocain,  63 

Hubs,  for  syringes,  57 


111  effects  in  local  anesthesia,  159 
Impacted  teeth,  175 
Incisive  injection,  138 
Infiltration  anesthesia,  93 
Infraorbital  injection,  extraoral,  157 

intraoral,  134 
Injection,  alcohol  for  neuralgia,  174 

buccinator,  126 

endermic,  98 

extraoral,  144 

for  a  number  of  teeth,  109 

horizontal,  no 

incisive,  138 

individual  teeth,  104 

infraorbital,  134 

intraoral,  113 

mandibular,  144 

maxillary,  152 

mental,  123 

on  labial  and  buccal  side  of  upper 
jaw,  102 

on  labial  side  of  mandible,  103 

on  lingual  side  of  mandible,  104 

on  lingual  side  of  upper  jaw,  103 

palatine,  139 

pterygomandibular,  113 
extraoral,  148 

sphenomaxillary,  126 


INDEX 


179 


Injection,  subcutaneous,  98 

tables,  140,  141,  142,  143 

zygomatic,  132 
Innervation  of  oral  tissues,  3  7 
Insertion  of  needle,  preparing  place  for, 

87 
Instrumentarium,  54 
Instruments,  fault}',  160 


Jar  for  syringes,  59 

Jaws,  fractured,  175 

lower,  anatomy  of,  29 
resection  of,  1 76 
upper,  anatomy  of,  19 
operations  on,  175 


Kells,  still,  78 


Lamp,  alcohol,  60 
Lesions,  tissue,  165 
Lewis,  169 

Local  anesthesia  vs.  general,  18,  168,  i 
176 

M 
^Mandible,  anatomy,  29 
Mandibular  injection,  144 
Margin,  infraorbital,  21 
Maxilla,  anatomy,  19 

anterior  surface,  19 
Maxillary  injection,  152 

nerve,  25 
Medication,  postanesthetic,  170 

preanesthetic,  86,  176 

postoperative,  170 
Method  of  pulp  anesthesia,  92 
Morphia,  86 
Mucous  membrane,  infiltration  of,  q6 

preparation  of,  87 

N 
Nasal  anesthesia,  91 
Nausea,  164 
Needle,  breaking  of,  161 
for  injection,  55 
extraoral,  61 


Needle,  iridio-platinum,  56 

steel,  56 
Nerve,  fibers  torn,  161 

motor,  anesthesia  of,  162 
trunks  entered  by  needle,  161 
Nerves,  anterior  palatine,  45 

anterior  superior  alveolar  ramus,  43 
auriculotemporal,  49 
buccinator,  48 
frontal,  39 
inferior  alveolar,  49 

dental  rami,  51 

gingival  rami,  51 

palpebral  rami,  44 
infraorbital,  44 
infratrochlear,  42 
labial,  superior,  44 
lacrimal,  39 
lingual,  49 
mandibular,  48 
maxillary,  42 
mental,  51 
middle  palatine,  46 
middle  superior  alveolar  ramus,  43 
nasal,  external,  42 

internal,  44 
nasociliary,  40 
naso-palatine,  46 
ophthalmic,  39 
palpebral,  inferior,  44 
posterior  superior  alveolar  rami,  42 
sphenopalatine,  42 
superior  dental  plexus,  44 
superior  dental  ramus,  44 
superior  gingival  ramus,  44 
supraorbital,  39 
supratrochlear,  39 
trigeminal,  38 
vidian,  44 
zygomatic,  42 
Neuralgia,   major,   alcohol  injection   for, 

174 
trifacial,  diagnosis  of,  174 
Novocain,  history  of  production  of,  64 

O 

Operations,  on  jaws,  175 
Operator,  personality  of,  17 
Ophthalmic  nerve,  39 


INDEX 


Oral  cavity,  anatomy  of,  19 

surgery,  175 


Pain,  162 

caused  by  original  puncture,  163 

control  of,  18 

nature  of,  15 

postoperative,  167 
Palatine  injection,  139 
Paleness,  164 
Palpitation,  163 
Papilla,  palatina,  26 
Patient,  apprehensive,  86 

preparation  of,  85 
Patrick's   formula  for   alcohol   injection, 

174 
Pharmacology  of  drugs  used,  62 
Phylogenetic  habits,  16,  162 
Plexus,  superior  dental,  44 
Pluglets,  procaine,  83 
Poisoning,  procaine,  69 
Postanesthetic  effects,  165 

medication,  170 
Postoperative  medication,  170 
Practical  application  of  local  anesthesia, 

171 
Preface,  7 

Preparation  of  the  solution,  author's 
method,  81,  83;  Seidel's  method, 
81 

local  of  patient,  87 

of  mucous  membrane,  87 

of  patient,  85 

of  skin,  87 
Procaine,  65 

chemical  reaction  of,  65 

dosage,  66 

incompatibles,  66 

Metz,  64 

name  substituted,  8 

physiological  properties,  66 

pluglets,  83 

toxic  properties,  66 
Procaine-suprarenin,  combined,  80 

in  ampules,  80 

prepared  solution,  81 

Seidel's  method,  81 

Tablets,  author's  method,  81 


Process,  alveolar,  of  maxilla,  23 

palatal,  25 

zygomatic,  23,  24 
Psychic  effects,  17 

Pterygomandibular    injection,   extraoral, 
148 

intraoral,  113 
Pulps,  after  local  anesthesia,   168 

anesthesia  of,  91 

inflamed,  172 

removal  of,  1 73 
Pyorrhea  alveolaris,  treatment  of,  174 

Q 

Quinine  urea  hydrochlorid,  63 

R 

Ramus  of  mandible,  anterior  surface,  37 
Removal  of  pulps,  173 
Requirements    of    a    solution    prepared 
from  tablets,  84 

of  a  substitute  for  cocain,  63 
Resection  of  jaws,  176 
Respiration,  artificial,  69 
Ridge,  infraorbital,  21 
Ringer  solution,  75 

tablets,  76 
Roth,  67 

Rules  for  selecting  methods  of  local  anes- 
thesia, 171 


Salt  solution,  physiological,  75 

Seidel's  method  of  preparing  Novocain- 

suprarenin  solution,  81 
Sharpening  of  needle,  57 
Shock,  16 

psychic,  162,  17,  164 
Sinus,  maxillary,  28,  19 

operations  on,  175 
Skin,  infiltration  anesthesia  of,  96 

preparation  of,  87 
Smith,  syringe,  129 
Solution,  for  syringes,  59 

preparation    of,    81,     83;      author's 
method,  81 

requirements  if  prepared  from  tablets, 
84 
Solvent  medium,  75 


INDEX 


ibi 


Sphenomaxillary  injection,  126 
Still,  Kells,  78 
Subcutaneous  injection,  98 
Sulcus  mandibularis,  29 
Suprarenin-s>-ntheticum,  71 

chemical  properties,  71 

dosage,  74 

incompatibles,  72 

phj'siological  properties,  72 

production,  71 

toxic  properties,  73 
Surface,  anesthesia,  89 

anterior  of  maxilla,  19 
of  ramus,  37 

external  of  mandible,  29 

infratemporal,  22 

internal  of  mandible,  31 
Surgery,  oral,  175 
Sweating,  163,  164 
SjTicope,  164 

treatment  of,  165 
SjTinges,  for  extraoral  method,  60 

for  intraoral  method,  54 

T 

Table   for  conduction  anesthesia  of    the 

teeth  only,  142 
for    conduction    anesthesia    of    the 

teeth  and  soft  tissue,  143 
for    infiltration    anesthesia    of     the 

teeth  only,  140 
for  infiltration     anesthesia     of     the 

teeth  and  soft  tissue,  141 


Table  for  the  selection  of  needles,  57 

of  comparative  toxicity,  67 

of  nerve  supply,  52,  53 
Tablets  of  Procaine-suprarenin,  81 

E,  82 

EF,  82 

H,  82 

Mixing,  82 

Ringer,  76 

T,  82 
Technique,  faulty,  160 

of  local  anesthesia,  89 
Teeth,  extraction  of,  175 

impacted,  175 
Tray,  glass,  for  novocain  tubes,  59 
Treatment  of  syncope,  69,  164 
Trembling,  163 
Tropacocain,  63 
Tuber  maxillare,  23 
Tumors,  175 


Validol,  69,  165 
Vasoconstriction,  161 
Veronal,  86 

W 

Water,  distilled,  77 
Wisdom  teeth,  impacted,  175 


Zygomatic  injection,  132 


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